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and the Maldives) and a collective population of more than 1.3 billion people. 10% of the world's suicides (more than 100,000 people) take place in just three of ...
Murad M. Khan: Suicide on the Indian Subco ntinent

Crisis 23 (3), © 2002 Hogrefe & Huber Publishers

Research Trends

Suicide on the Indian Subcontinent Murad M. Khan Department of Psychiatry, The Aga Khan University, Karachi, Pakistan Summary: The Indian subcontinent comprises eight countries (India, Pakistan, Bangladesh, Nepal, Sri Lanka, Afghanistan, Bhutan, and the Maldives) and a collective population of more than 1.3 billion people. 10% of the world’s suicides (more than 100,000 people) take place in just three of these countries, viz. India, Sri Lanka, and Pakistan. There is very little information on suicides from the other four countries. Some differences from suicides in Western countries include the high use of organophosphate insecticides, larger numbers of married women, fewer elderly subjects, and interpersonal relationship problems and life events as important causative factors. There is need for more and better information regarding suicide in the countries of the Indian subcontinent. In particular, studies must address culture-specific risk factors associated with suicide in these countries. The prevention of this important public health problem in an area of the world with myriad socio-economic problems, meager resources, and stigmatization of mental illness poses a formidable challenge to mental health professionals, policy makers, and governments of these countries. Keywords: Indian subcontinent, suicide, India, Pakistan, Sri Lanka

Introduction The Indian subcontinent represents a major part of the world’s population, both in numbers and in the variations in religions, ethnicity, socio-economic status, and types of physical and mental health care. It consists of eight countries, i. e., India, Pakistan, Afghanistan, Sri Lanka, Bangladesh, Nepal, Bhutan, and the Maldives. Collectively, these countries comprise more than 1.3 billion people, which makes it one of the most populous regions of the world. Although many of the countries have their distinct culture, language, traditions, and religions, they also share many common factors, particularly in family traditions, attitudes toward the elderly and women, socio-economic conditions, and problems of overpopulation and low literacy rates. Many of the world’s major religions are represented in the Indian subcontinent including Islam, Hinduism, Buddhism, Sikhs, and Christianity. All these religions condemn suicide in one form or other.

Suicide in the Subcontinent Although suicide is a major public health problem globally and the subject is receiving considerable attention in the West, little is being done to address the problem in the countries of the developing countries, where large numbers Crisis 2002; Volume 23 (3): 104–107 DOI: 10.1027//0227-5910.23.3.104

of suicides take place. Many of the countries of the Indian subcontinent fall into this category. Information on suicide on the Indian subcontinent stems mostly from India, Sri Lanka, and Pakistan. Of the remaining countries, viz. Bangladesh, Afghanistan, Nepal, Bhutan, and the Maldives, virtually nothing is known. Most of these countries have poorly developed mental health services and mental health issues including suicidal behavior are given little importance where the priorities are infectious diseases, sanitation, and housing.

Problems of Data Collection There are considerable problems in certifying and recording suicides in the countries of the Indian subcontinent. There are legal, social, and religious reasons for this. For example, suicide is considered a criminal act in Pakistan, punishable with a jail term and heavy financial penalty (Khan, 1998). In India, until 1994, attempted suicide was a punishable act. In 1994 this provision was declared to be unconstitutional. However, threats from euthanasia groups and problems relating to dowry deaths have restored the penal status of attempted suicide in India (Murthy, 2000). To avoid harassment by the authorities many suicide cases are taken to private hospitals that neither record such cases © 2002 Hogrefe & Huber Publishers

Murad M. Khan: Suicide on the Indian Subcontinent

as suicide nor report them to the police, instead diagnosing them as “accidental.” The social stigma of suicide in a family is enormous. Such families are ostracized and viewed with suspicion. There can be other implications as well, for example, on the marriage prospects of the girls in the family. The problem is therefore grossly underreported, and the true rates of suicide may be many times higher than the official figures in the countries of the Indian subcontinent.

Incidence In India about 90,000 people kill themselves every year (Vijaykumar, 1998). In the ranking of nations by total number of suicides India is second only to China with 195,000 suicides. Suicide rates in India have shown a gradually increasing trend. The rate in 1996 was 9 per 100,000. There is a large variation in suicide rates in different parts of India and states and cities with rapid social change appearing to be associated with higher rates (Murthy, 2000). Sri Lanka has one of the highest suicide rates in the world. In 1995 the rate of suicide was 47 per 100,000, and in some regions of the country the rate has now reached 118 per 100,000 (Ratnayeke, 1996). In Pakistan, a conservative Muslim country with traditionally low suicide rates, the suicide incidence appears to have increased quite significantly over the last 2–3 years (HRCP, 2000). Between 1996 and 1997 there were only 306 suicides (Khan & Reza, 2000), but in 1999 there were over 2000 suicides, and between January and August 2000 the figure was reported as 2100 (HRCP, 2000). Thus, only three countries of the Indian subcontinent contribute 10% (or 100,000) of the total burden of the estimated 1 million suicides worldwide. Of all the countries of the Indian subcontinent only Sri Lanka reports its suicide mortality figures to the World Health Organization (World Health Annual Statistics, 1992).

Age and Gender Like many other parts of the world, young people on the Indian subcontinent between the ages of 20 and 30 years appear to be most vulnerable group. In Sri Lanka about a quarter of suicides are by people under the age of 30 years (Ratnayeke, 1998). In India similar trends prevail with the highest rates in the age groups 20 to 30 years (Venkoba Rao, 1983). Studies from Pakistan show that between 50% and 82% of subjects are under the age of 30 years (Ashraf, 1964; Ahmed & Zuberi, 1981; Khan & Reza, 2000). In Sri Lanka three times as many men as women kill themselves. Figures for years 1991 to 1995 show that 28,618 men and 9899 women killed themselves (Ratnayeke, 1998). Two studies based on police records in Paki© 2002 Hogrefe & Huber Publishers

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stan showed men to women ratio as 2.7:1 and 1.2:1 respectively (Ashraf, 1964; Ahmed, 1981) while a third study of 44 suicides presenting to a government hospital showed 55% women (Ahmed, 1983). A more recent study of 306 suicides showed the male to female ratio to be 2:1 (Khan & Reza, 2000). In India, the association between suicide and gender is inconsistent. Some studies report male preponderance (Sarma & Sawang, 1993), while others report a female majority (Bannerjee et al., 1990). Whatever the true ratio, it appears to be much narrower than the 3:1 or 4:1 male-to-female ratio consistently reported in the West. The issue of family prestige and importance given to the male as a significant role model on whom the entire family is judged may partly explain the narrow ratio between the genders. Unlike in the West, rates of suicide in the elderly are low in the Indian subcontinent. Several factors may be contributing to this. The average life expectancy is much lower in developing countries, while at the same time, the elderly not only enjoy a position of privilege, but also continue to be looked after by their families after retirement and seldom have to fend for themselves. They continue to play an active role, and their opinion is always sought in important family matters. Over the last few years, though, the migration of younger people to urban areas within the country as well as to other countries has resulted in changes in family structures, leaving the elderly exposed to social problems. Whether this has led to higher rates of psychiatric morbidity and subsequently suicidal behavior in the elderly in these countries are areas of future research.

Women and Marital Status The issue of marital status and suicide is an important one in the context of suicidal behavior in the countries of the Indian subcontinent. As many of the societies of the Indian subcontinent are strongly patriarchal, marital status for women assumes much more importance than it does in countries of the developed world. Studies from India (Ponnudurai & Jayakar, 1980) and Pakistan (Khan & Reza, 2000) have highlighted the increased incidence of suicide in married compared to single or divorced women. Some of the associated factors are early marriage and motherhood, infertility or absence of male offspring, lack of autonomy in choosing marital partner and economic dependence on husband (Khan & Reza, 1998). Studies from Pakistan and Bangladesh have also highlighted the problem of domestic violence toward women (Fikree & Bhatti, 1999; Zaman, 1999). Case studies from other developing countries suggest that if a woman’s support group does not defend her when she is the victim of violence that passes the bounds of normative behavior, her suicide may be revenge suicide, intended to force others to take vengeance on the abusive husband (Counts, 1987). Among young married women who engage in suicidal Crisis 2002; Volume 23 (3): 104–107

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behavior, marital and family conflict, especially with inlaws, appears to be a major predisposing factor (Khan & Reza, 1998). It is important to bear in mind, though, that the number of single and divorced women in the Indian subcontinent is much lower than in the developed countries, which may contribute to the high incidence of suicide among married women in these countries.

Methods Employed Common methods of suicide appear to be hanging, ingestion of organophosphate insecticides, drowning, and burning. Other methods, for example, using firearms, jumping from a height or in front of a train, and taking an overdose of psychotropic medications, are used less frequently. Organophosphate insecticides are lethal when ingested, and their easy availability and accessibility probably contributes to the high fatality in Sri Lanka, India, and Pakistan (Ratnayeke, 1998; Vijaykumar & Rajkumar, 1998; Khan & Reza, 2000).

Precipitating Factors Previous studies from the Indian subcontinent showed mental illness to be rarely reported as a cause of suicide. Instead interpersonal relationship problems with significant others, especially family members was frequently reported (Ahmed, 1983; Ganesvaran et al., 1984; Bhatia et al., 1987). However, Vijaykumar and Rajkumar (1999), in a more recent psychological autopsy of 100 consecutive suicides in India, showed a lifetime DSM-III-R Axis I disorder in 88% cases, with alcoholism and mood disorders being the most common diagnoses. It is possible that in developing countries psychiatric disorders are underestimated because of the stigma of mental illness as well as limited treatment resources (Bhatia et al., 1987).

Prevention of Suicide There has been very little work done on the prevention of suicide in the countries of the Indian subcontinent. In India and Sri Lanka, a few suicide-prevention centers are operating with encouraging results (Vijaykumar, 1998; Ratnayeke, 1996). Sumithrayo Befrienders, a voluntary organization in Sri Lanka, is an example of one such center. There are many difficulties in establishing a suicide prevention center in developing countries where mental health has a very low priority. The concept of volunteerism and external support is alien to many of the countries of the Indian subcontinent where problems have traditionally been managed within the family set-up. But rapid urbanCrisis 2002; Volume 23 (3): 104–107

ization, industrialization, and changes in family structures have resulted in the breakdown of traditional support systems. There is therefore the need for external support system (Vijaykumar, 1998)

Future Research There is a need for more and better information concerning the risk factors for suicide in the countries of the Indian subcontinent. In particular, there is need for information from the countries of Bangladesh, Nepal, and Afghanistan. These countries as well as India and Pakistan should be encouraged to report their suicide mortality statistics to the World Health Organization. This would ensure better diagnosis and registration of deaths by suicide. One issue that requires particular attention is that of the laws regarding suicide and attempted suicide in the countries of the Indian subcontinent. The “criminalization” of attempted suicide has led to stigma, avoidance of seeking help, and a lack of involvement of professionals in developing suicide preventive programs (Murthy, 2000). There is an urgent need to review and modify the law regarding suicide so that people who attempt suicide—and are at risk for further attempts—can seek help without fear of being persecution by the police. It is doubtful whether the law on suicide has any deterrent value.

Conclusions The countries of the Indian subcontinent are home to more than a billion people. These countries share many cultural, social, and traditional values while also facing similar social, economic, and political problems. The fact that at least 100,000 people kill themselves in these countries every year (and thousands more probably attempt to do so) is a human tragedy that needs to be addressed urgently. It is therefore imperative in this new millennium that not only the study, but also the prevention of suicide become a main priority for mental health professionals, policymakers, and governments of the countries of the Indian subcontinent.

References Ahmed SH, Zuberi H. Changing pattern of suicide and parasuicide in Karachi. Journal of the Pakistan Medical Association 1981; 31:76–78. Ahmed SH. Pakistan. In LA Headley (Ed.) Suicide in Asia & the Near East. Berkley & Los Angeles: University of California Press 1983, pp. 258–271. Ashraf M. The problem of suicide in Karachi. Pakistan Armed Forces Medical Journal 1964; 14:156. Bannerjee G, Nandi DN, Nandi S. The vulnerability of Indian © 2002 Hogrefe & Huber Publishers

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women to suicide—A field study. Indian Journal of Psychiatry 1990; 32:305–398. Bhatia ZA, Khan MH, Mediratta RP et al. High risk suicide factors across cultures. International Journal of Social Psychiatry 1987; 33:226–236. Counts DA. Female suicide and wife abuse: a cross-cultural perspective. Suicide & Life Threatening Behavior 1987; 17:194– 204. Fikree FF, Bhatti LI. Domestic violence and health of Pakistani women. International Journal of Gynecology & Obstetrics 1999; 65:195–201. Ganeswaran T, Subramaniam S, Mahdevan K. Suicide in a northern town of Sri Lanka. Acta Psychiatrica Scandinavica 1984; 69:420–425. HRCP (Human Rights Commission of Pakistan). Quoted in The Dawn, Nov. 6, 2000. Khan MM, Reza H. Gender differences in nonfatal suicidal behavior in Pakistan: Significance of socio-cultural factors. Suicide & Life Threatening Behavior 1998; 28:62–68. Khan MM. Suicide and attempted suicide in Pakistan. Crisis 1998; 19:172–176. Khan MM, Reza H. The pattern of suicide in Pakistan. Crisis. 2000; 20:67–70. Murthy RS. Approaches to suicide prevention in Asia and the Far East. In K Hawton & K van Heeringen (Eds), The international handbook of suicide and attempted suicide. Chichester: Wiley 2000, pp. 631–641. Ponnudurai R, Jeyakar J. Suicide in Madras. Indian Journal of Psychiatry 1980; 22:202–203. Ratnayeke L. Suicide and crisis intervention in rural communities in Sri Lanka. Crisis 1996; 17:149–154. Ratnayeke L. Suicide in Sri Lanka. In RJ Kosky et al. (Eds), Suicide prevention: The global context. New York: Plenum, 1998. Sarma GP, Sawang GD. Suicides in rural areas of Warangal district. Indian Journal of Behavioral Sciences 1993; 3:79–84. Venkoba Rao A. India. In LA Headley (Ed). Suicide in Asia and

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Near East. Berkley and Los Angeles: University of California Press, 1983, pp. 210–237. Vijaykumar L. Establishing a suicide prevention center in India. In RJ Kosky et al. (Eds), Suicide prevention: The global context. New York: Plenum, 1998. Vijaykumar L, Rajkumar S. Are risk factors for suicide universal? A case-control study in India. Acta Psychiatrica Scandinavica 1999; 99:407–411. World Health Statistics Annual. Geneva: World Health Organization, 1992. About the author: Murad M. Khan, MD, MRCPsych, is Associate Professor in the Department of Psychiatry at the Aga Khan University, Karachi, Pakistan. He is a member of the IASP and has served on the Stengel Research Award Committee. His research interests include sociocultural factors in suicidal behavior, epidemiology of suicide, and mental health of women. He is currently engaged in a psychological autopsy study of suicides in Karachi in collaboration with the Institute of Psychiatry, London, UK, where he holds an honorary appointment. Address for correspondence: Murad M. Khan Department of Psychiatry The Aga Khan University, Karachi Stadium Road PO Box 3500 Karachi 74800 Pakistan Tel. +92 21 493-0051 Fax +92 21 493-4294 E-mail [email protected]

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