A public health approach to suicide prevention in the Indian setting

Roy Abraham Kallivayalil; Bettina Sara Mathew

doi:10.4103/tjp.tjp_45_22

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Year : 2022 | Volume : 8 | Issue : 2 | Page : 63-67

A public health approach to suicide prevention in the Indian setting

Roy Abraham Kallivayalil¹, Bettina Sara Mathew²
¹ Department of Psychiatry, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
² Senior Resident in Psychiatry, Govt Medical College, Kottayam, Kerala, India

Date of Submission	03-Nov-2022
Date of Acceptance	14-Nov-2022
Date of Web Publication	16-Dec-2022

Correspondence Address:
Prof. Roy Abraham Kallivayalil
Department of Psychiatry, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla - 689 101, Kerala
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjp.tjp_45_22

Abstract

Suicide prevention should be one of the top global priorities. A public health approach is the one which is likely to produce the best results. Suicide prevention cannot be achieved in isolation – addressing the social determinants of health and mental health is integral to this. Identifying collaborators, situation analysis, assessing the availability of resources, advocacy, gaining commitment of the political leadership, and tackling stigma are integral components. Suicide prevention should be aimed at all levels – primary, secondary, and tertiary. Increasing awareness, identification of risk and protective factors, training of primary care physicians and other health personnel, helplines, restriction of the means, responsible media reporting, and multisectoral collaboration are important strategies.

Keywords: Collaboration, media, public health, social determinants, Suicide prevention

How to cite this article:
Kallivayalil RA, Mathew BS. A public health approach to suicide prevention in the Indian setting. Telangana J Psychiatry 2022;8:63-7

How to cite this URL:
Kallivayalil RA, Mathew BS. A public health approach to suicide prevention in the Indian setting. Telangana J Psychiatry [serial online] 2022 [cited 2023 Jun 5];8:63-7. Available from: https://tjpipstsb.org/text.asp?2022/8/2/63/363978

“The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss and have found their way out of the depths”

–Elisabeth Kübler-Ross

The WHO and the Global Burden of Disease estimate that approximately 703,000 persons die by suicide globally every year, which counts to around one death by suicide every 40 s. It is the fourth leading cause of death among 15–19-year-olds, who are the future contributors to the society, especially in the area of economic development and in short, for shaping a better world. At the other end, the older age group was also found to be at high risk in many countries. The overall global age-standardized suicide rate was 9.0 per 100,000 population according to the census of 2019, higher in males (12.6 per 100,000) than in females (5.4 per 100,000). Studies also show that the lifetime prevalence of suicidal ideation varies between 14% and 18% and about 1 in 9 adults with suicidal ideation make a suicide attempt. This highlights the need of suicide to be considered a serious public and social issue.^[1]

Social, psychological, cultural, biological, genetic, and various other factors interact to influence suicidal behavior. Various immediate and long-term impacts of suicide are reported among the survivors, partners, family, and friends. However, the associated stigma is one of the major hindrances to help-seeking. Despite being a sensitive issue, it is usually under-reported, criminalization of suicide and poor surveillance techniques being one of the few causes. The low- and middle-income countries accounted for the larger part of global suicides (77%). These countries have relatively less resources and inadequate infrastructure for health in general and also to prevent suicide. They often find it difficult to keep up with the rising demand of mental health care.^[2],[3],[4]

Although the systematic reviews by Farooq et al. and John et al. show no consistent evidence in the rise of suicide with COVID-19, the National Crime Records Bureau of India reports a whopping rise of 10% in the total suicides in the country from 2019 to 2020. The suicide rates have also gone up from 10.4% in 2019 to 11.3% in 2020 and the daily wage workers made the largest share of total suicides that year. Pandemic-related disruptions such as unemployment, economic contractions, and migrant crises may be the reasons for this crisis situation.^[5],[6]

However, suicide is preventable to a large extent and should be raised as a public health concern. Effective tools to significantly reduce loss of life by suicide are available. With a collaborative approach to acknowledge it as a serious problem along timely and beneficial interventions, and political and national support, preventing suicide is within reach.

Steps to Develop and Implement Suicide Prevention Strategies

Considering the magnitude of the problem of suicidal behaviors, a comprehensive national suicide prevention strategy needs to be urgently developed by the governments that explore the problem and lay out specific actions that can be executed at different levels. It is also necessary to review the existing national health-related policies and strategies to ensure that these measures fit with the overall health development policy. This will facilitate the identification of any existing gaps with regard to suicide prevention and provide opportunities to pitch in the changes required.^[7]

Identifying the collaborators

As suicide prevention demands a multisectoral approach, involving health-care professionals as well as representatives from other sectors is essential in developing a strategy.

Representatives from various government sectors, including the Ministry of Health, Education and Social Welfare, parliamentarians, policymakers, and politicians could make a positive contribution
Mental health services, including service managers, psychiatrists, psychologists, mental health nurses, and social workers, from both the public and the private sectors, are requisites for suicide prevention
The involvement of general public health sector, including public health managers, doctors, nurses, emergency care staff, administrators, and other service providers, is also important
The education sector, including teachers, school counselors, administrators, and student leaders, should be included as indispensable contributors to the prevention of suicide
Legal authorities, police, fire services, ambulance services, courts, and defense forces could also be included
A crucial role can be played by the survivors and families, various spiritual and religious leaders, nongovernmental organizations (NGOs), and media.^[3]

Surveillance and situation analysis

The next step is to define the problem of suicidal behavior through systematic data collection. Estimates of annual incidence of suicide and suicide attempt with respect to geographical areas and sociodemographic factors are to be included. This will help to identify the vulnerable population. It should also indicate the common methods of suicide and assess the accessibility and availability of services to those who attempt suicide.

The analysis should identify the existing gaps in the health system and the presence of various policies such as to reduce the harmful use of substances, especially alcohol, audit the quality of media reporting on suicide, consider the quality of statistics on suicide and suicide attempts, assess the quality of existing surveillance systems, and identify any gaps that exist in data collection.

Assessing the requirement and availability of resources

The availability and accessibility to manpower and financial resources is pivotal to the success of any health intervention. This can be assessed in three steps: first, by finding the human and financial resources required to formulate and implement a suicide prevention strategy; second, acquiring knowledge on the currently available resources; and finally, analyzing the gap and how to meet these demands.

Evaluating human resources involves the identification of primary care and mental health professionals; community-based health workers and others; personnel involved in developing and implementing policies on mental health; counselors at educational institutes, job places, and prisons; and first-line service providers including emergency, police, and fire services. Potential sources for funding and support need to be identified. They include budgets by central governments for suicide prevention, allocation by state or local governments, funding from philanthropists or foundations, aid from NGOs, and support from international agencies;

Achieving a commitment from the political leaders

Political guarantee and promise is necessary to assure that suicide prevention receives the resources and attention required from national and state leaders. Increasing awareness among national and state leaders; frequent publication of well-researched policy papers on suicide prevention; identification of empathizing political leaders, particularly with the issue; and adequate reference to suicide as a public policy issue in the media are ways to build up political support.^[3],[8],[9]

Tackling stigma

Stigma continues to be one of the major roadblocks to suicide prevention. Both mental illness and suicide are stigmatized which prevent people from help-seeking and hinder them in accessing suicide prevention services. This may also result in poor reporting and data collection. Social isolation, low self-esteem, and hopelessness are some of the consequences of stigma, which are predictors of suicide. Interventions to reduce stigma including increasing awareness and decriminalizing suicide, with efforts from the general population as well as the governments, can be beneficial.^[10]

Levels for Suicide Prevention

Suicide prevention can be divided into three levels:

Primary: Primary prevention aims to provide programs and services to prevent a suicide attempt. It focuses on reducing the risk factors and promoting the protective factors associated with suicide
Secondary: Secondary prevention aims to provide programs and services after an attempted or completed suicide. It addresses the short-term impact and effects of suicide
Tertiary: Tertiary prevention programs and services are long-term responses and plans to address the after-effects and consequences of suicide such as providing care.^[11],[12]

Key Components in Suicide Prevention Strategy

Increasing awareness

Awareness campaigns may be conducted to improve public knowledge about mental health and suicide which may change the attitude toward mental illness and help in better recognition of illnesses and in seeking treatment. Mental health professionals and other stakeholders including media can come together and generate a better understanding about the existing problem and increase participation in suicide prevention.

Identifying the risk factors and protective factors

Evaluating the causes and finding out what can buffer their impact is vital for suicide prevention. Social and environmental factors such as various cultural and religious views, social isolation, lack of support from the community, economic crises, stigma, and migration are related to the increasing rates of suicide. Easy access to lethal means such as firearms, medications, and pesticides; unhealthy portrayal of suicide by media; and lack of availability and accessibility of resources for suicide prevention, especially in low- and middle-income countries, have noticed to heighten the risk. Physical illnesses, traumatic events, and interpersonal stressors occurring in adulthood are also found to influence the rates.

Several individual factors such as family history, personality traits, and cognitive styles pose a significant risk for suicide. Exposure to early life adversities is another well-acknowledged risk factor which includes parental neglect, childhood physical, sexual or emotional abuse, and chronic poverty. A previous suicide attempt is the strongest risk factor for death by suicide. Poor problem-solving, decision-making, and coping skills also mediate the risk. The presence of psychopathology is an important predictor of suicide. Major depressive disorders and bipolar disorder in mixed-state episodes are particularly at risk.

In addition, other factors such as age, gender, marital status, and geographic location also influence suicide. Suicide attempts are more often seen in the younger age group, particularly in females. However, the rates of completed suicides are over twice as high among men than women. Suicide rates are high within vulnerable groups who are subjected to discrimination including refugees, migrants, prisoners, indigenous people, and individuals from the LGBTI community. Positive family and community support, spirituality, sense of responsibility, life satisfaction, positive coping skills, and positive problem-solving skills were noted to be some of the protective factors.

Training general medical practitioners and other health personnel

The primary care setting and the emergency department are key areas where suicide screening must be implemented. General practitioners should be trained in diagnosing and treating depression, which would help in early detection and timely intervention. The approach can be extended to the detection of other psychiatric disorders too, including substance use disorders, that increase the suicidal risk. Emergency room doctors should also be trained on sensitive and empathetic handling of persons who have attempted suicide and provide clear referrals to mental health services. Nurses and community health workers can also be included in the training to identify suicidal behaviors and provide immediate support to a person experiencing suicidal distress.^{[13],[14],[15]}

Gatekeeper training

The term “gatekeeper” refers to “individuals in a community who have face-to-face contact with large numbers of community members as part of their usual routine.” Community, organizational, and institutional gatekeepers such as religious leaders, police officers, teachers, coaches, and those who work in prisons, juvenile detention, welfare centers, workplaces, and homes for the elderly can be trained to identify persons at risk of suicide and refer them for appropriate management. Studies show that a 3–6-month training period by mental health professionals is effective, where they can be educated about the suicidal burden, risk factors, warning signs, support system available, signs of depression, communication, and counseling skills to address the at-risk population. The gatekeepers could encourage early mental health intervention, promote help-seeking, destigmatize mental health issues, increase protective factors such as social connectedness and social support, and improve coping skills.^[16]

24-h helpline services

Access to 24-h crisis care is one of the most important aspects of mental health service provision in the prevention of suicide. Telephonic and Internet-based suicide hotlines are useful, where professionals/people with focused training can provide brief psychotherapy and crisis intervention. These services can allow time for the crisis to dissipate and provide appropriate referral pathways for further clinical assessment and intervention.

Restriction of means of suicide

Restriction of (suicide) methods is effective to reduce suicidal risk. Impulsivity is a component of suicide, and therefore, restricting access to lethal means would enable the suicidal thoughts to alleviate. It is a beneficial strategy to curb suicidal behaviors as it will address large populations including those in whom the risk remains undetected. Legislations restricting access to firearms, installing barriers at jumping hotspots and CCTV at other prone sites, restricting the availability of pesticides, limiting over-the-counter availability of medicines, and short-duration prescriptions by doctors are some of the ways in which this can be facilitated. A case-controlled study conducted in Kerala focused on farmers noted that hanging and organophosphate poisoning are the most common methods of suicide, which indicates the need for these restrictions.^[13],[17]

Impact of media

The influence of media has expanded over the years. Suicides are often sensationalized with explicit descriptions and details. This can trigger imitative attempts (copycat suicides/Werther effect) by the vulnerable group of people. Hence, media guidelines for reporting and portraying suicides should be followed. Neutral and discreet reporting, keeping in mind the possible psychological harm on survivors, is suggested. Providing knowledge, de-stigmatizing mental illness, and encouraging people to approach mental health professionals in time of need can be well-communicated through media.

Identification and treatment of mental disorders

Early identification and intervention can create a huge difference to an individual's life. Pathways to seek help from a mental health professional should be paved out. Effective treatment and long-term care for those with mental illness will substantially decrease the rates of suicide. Pharmacological and psycho-social interventions have proven to be useful in suicide prevention. People who make suicide attempts are at increased risk of making further attempts, and of dying by suicide, especially the first 3 months following a suicide attempt. Studies have shown that focussed interventions and regular follow-up reduce the risk of future attempts. Support and education to the family members, friends, and community impacted by suicide are important both to reduce the stress experienced by the suicide survivors and to reduce further suicide attempts.

Other measures

Public health measures can contribute to suicide prevention through the promotion of protective factors and environments. Financial and housing security issues must be addressed by governments and leaders. Social services and supports can reduce isolation, promote life skills, and provide practical support to vulnerable individuals and families to improve their quality of life. People from vulnerable communities can face additional barriers in accessing support, including language and cultural differences, experiences of discrimination, religious beliefs, or concerns about confidentiality. Hence, special attention should be given to these vulnerable individuals.^[13],[18]

Case registration, research, and evaluation

Population-based surveys and research on suicidal behaviors should be encouraged. A comprehensive monitoring and evaluation of suicide prevention strategies should also be done to assess the quality and effectiveness of interventions. These evaluations will be effective in making essential and timely modifications in the interventions, such as changes needed in the postpandemic scenario.^[3]

Conclusion

Suicide prevention should be one of the global priorities. It can be achieved only through a variety of interventions including addressing the social determinants of health and mental health. Addressing illiteracy, poverty, and social exclusion is very important in countries like India. Increasing the health and mental health infrastructure and improving access to care should be topmost in the agenda.^[19] Responsible media reporting and mental health advocacy are crucial.^[20] Suicide prevention needs collective and collaborative efforts of the government, policymakers, local community, and health professionals. Adequate resources should also be ensured for implementing these strategies. Reducing suicide burden will in turn reduce the global burden of disease, besides saving thousands of lives. That should be our cherished goal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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