Contrary to popular belief, almost eight out of ten individuals who contemplate suicide give warning signals to indicate they need help. For every death by suicide, there are around 20 to 50 attempts, making it imperative to address both survivors of failed suicide bids and the grieving friends and relatives of the deceased. Rising numbers indicate that suicide is a public health problem that requires broad based, multi-tiered interventions.
Most suicide prevention strategies are based on patchy data, owing to suicides being mis-reported as death by other causes and because of the reluctance in reporting suicidal attempts. According to the WHO’s 2002 world report on violence and health, 85 per cent of suicides occur in low/middle income countries, but they account for less than 10 per cent of published research.
Self-harm is criminalised in many countries, including India, and most policies are narrowly focussed on mental illness rather than comprehensive mental well being. In India, attempted suicide is a punishable offence under Section 309 of the Indian Penal Code, carrying imprisonment upto one year. This often leads to the harassment of vulnerable or mentally disturbed individuals, and prevents survivors from seeking guidance or counselling.
According to Dr Achal Bhagat, Director of the NGO Saarthak, a new national mental health policy is required, which would be ‘preventive in scope and would treat mental health as a development issue.’ He advocates a ‘cross-sectoral approach’, integrating mental health service delivery with social development programmes, tapping into their network and resources to maximise the outreach and impact.
Less than one per cent of India’s total health budget is spent on mental health, with a large chunk being devoted to communicable diseases. A national mental health programme has been in place since 1982, but its implementation has been hindered by a greater focus on illness rather than on comprehensive mental well being. Even the Mental Health Act of 1987 is narrow in focus relating to severe illnesses and disability.
According to Dr Rajesh Sagar, Associate Professor of Psychiatry at AIIMS and Secretary to the Central Mental Health Authority, ‘one of the main reasons that the objectives of the national mental health programme have not been met is due to the acute shortage of mental health professionals in India’. According to him, this can be partly addressed by providing additional training to primary health care professionals to deal with mental health problems.
For every 100,000 people, India has 0.4 psychiatrists, 0.04 psychiatric nurses, 0.02 psychologists and 0.02 social workers and 0.25 psychiatric beds, according to 2001 figures by WHO. To offset the gross shortage of manpower, intervention must start with sensitising the first line of contact in the community – schools, workplaces, emergency psychiatry and primary healthcare providers.
In most developing countries it is the easy access to prescription drugs and pesticides that translates into successful suicides bids and requires greater focus. An estimated 250,000 suicides globally are due to pesticide poisoning, a trend reflected in the growing recourse to this method by a number of farmers in India. Countries have sought to reduce access to lethal means by regulating pesticides, guns and psychotropic substances.
Many countries have set up national programmes, with Finland boasting of the world’s only large scale fully implemented and evaluated national suicide prevention programme, which enlisted the support of over 50,000 professionals from different fields. Between 1987-96, the suicide rate indicated a drop of 8.7 per cent, inspiring similar efforts across the globe.
Given the growing incidence of suicides, it is time to address the issue as a public health concern. A national prevention plan can only succeed as part of a broader development strategy.