Suicide in India: a systematic review

Suicide and its risk factors - An ecological study

BACKGROUND

There is tremendous variation in both the prevalence of suicide and the factors that contribute to its occurrence across geographic locations, cultures, and time. Therefore, the present study aims to identify the various socio-demographic risk factors and psychosocial stressors using population data.

MATERIALS AND METHODS

The countries that were included in the study were based on data from the World Health Organization. We considered the top ten suicide countries and the ten lowest suicide nations. We searched five global databases for the most recent socio-demographic data and data on psychosocial stressors during the period of August and September 2022. We analyzed the correlation between suicide rates and various factors, and we considered a P value of less than 0.05 to be statistically significant.

RESULTS

The correlation of suicide with sociodemographic factors like age (P 0.246), gender (male, P 0.357, and female, P 0.357), net enrolment rate (P 0.725), gender parity index (P 0.929), urban population percentage (P 0.571), marital status (male, P 0.345, and female, P 0.752), and literacy rate percentage (P 0.199) was not significant. The correlation of suicide with psychosocial stressors like unemployment percentage (P 0.552), alcoholism percentage (P 0.271), the prevalence of depression (P 0.523), the number of psychiatrists (P 0.605), the number of mental hospitals (r = -0.090, P 0.713), and the poverty rate percentage (P 0.538) were also not significant.

CONCLUSION

Suicide is a major public health issue, yet global suicide data is scarce. Sociodemographic factors like age, urbanization, and literacy rate were negatively correlated, whereas psychosocial stressors like unemployment, alcohol misuse, and poverty were positively correlated, but none were significantly associated.

Sociodemography, pattern, and response inhibition in suicide survivors: A case-control study

Introduction

Suicide is a global phenomenon. Psychiatric disorders are estimated to contribute to a large proportion of suicides; however, impulsive suicide is also common. Among the ages of 15-29 years, suicide was the second leading cause of death worldwide and has been hypothesized to have reduced response inhibition and decision-making abilities as contributing factors, which directly relate to impaired executive functioning and suicidal behavior.

Aim

This study aimed to study sociodemography, method, and pattern of suicide, and response inhibition in suicide survivors.

Material and Methods

A case-control study was designed in a tertiary medical center in Madhya Pradesh using convenient sampling of suicide survivors and controls from the general population over 3 months. Data collection was semi-structured pro forma, and response inhibition was assessed using the Stroop test. Statistical analysis was performed using IBM Statistical Package for the Social Sciences (SPSS) Windows version 25.0. Independent-samples Student's t-test, Chi-square test, and Mann-Whitney U-test were used for analyzing means of continuous data, nominal data, and ordinal data, respectively. The level of significance was at P < 0.05.

Result

A total of 126 suicide survivors and 99 controls were assessed after the end of the study period. Age (mean age for cases 25.4 ± 9.16; controls 23 ± 7.9), gender (F ~ M), and socioeconomic status were used to match cases and controls. 85.7% of suicide survivors had no history of suicide, but the majority had precipitating factors. Anomic suicide was the most common type, and poisoning was the most common method of suicide. Response inhibition between cases and control was significantly different.

Conclusion

The majority of suicide attempts were impulsive in youth, with no gender discrimination. Response inhibition seemed to play a role in a suicide attempt.

Analysis of Socio-Demographic Profiles of Suicidal Hanging Cases to Formulate a Preventive Strategy: An Autopsy-Based Study Conducted at a Tertiary Care Hospital in the North-East Region of India

Introduction Hanging is a common method of suicide in India and worldwide. Analyzing the socio-demographic characteristics to formulate a preventive strategy to reduce the incidence of suicide by hanging is often considered a low-cost but effective intervention for developing countries like India. The present study reports on preventive measures based on socio-demographic data of suicidal hanging cases brought for autopsy in a city in Northeast India. There is no scientific literature originating from the Northeast region of India that stresses on the preventive aspect of suicidal hanging cases to date.  Methods This is an observational study based on retrospective data. Data related to socio-demographic characteristics were collected from all the suicidal hanging cases reported for medicolegal autopsy at a tertiary care hospital in Dibrugarh, a city in Northeast India, from June 2012 to June 2013.  Results A total of 1241 cases were brought for autopsy, out of which 70 (5.64%) cases were determined to be death due to suicidal hanging. Male victims accounted for the majority of the cases, and most victims were in their third decade of life. Additionally, various other factors, such as marital status, occupational status, place of occurrence, psychiatric history, pregnancy status, and selection of suspension point, were studied. Conclusion Socio-demographic data generated from various research studies can play a crucial role in the early identification of vulnerable individuals and enable the prompt delivery of mental health services and other measures of interventions. Implementing policy-based strategies, such as restricting access to means and materials used in hanging, can have a positive impact on overall outcomes. Additionally, involving electronic or print media to de-popularize hanging as a clean and painless method proves to be another effective intervention.

Association Between Loneliness and Suicidal Behaviour: A Scoping Review

OBJECTIVE

Suicide is a public health issue, and there are several factors leading to suicide, like mental illness and psychosocial stressors. Actual loneliness (living alone) and subjective loneliness (feeling of being alone) and different suicidal behaviors have been reported to have some link. This scoping review aimed to assess the association between loneliness and suicidal behaviour by exploring the existing literature.

METHODS

A scoping review was conducted implementing the appropriate framework and in accord with the PRISMA-ScR extension. A PubMed database search was made using a combination of terms to find publications in English from 2011 to 2021. Studies were included if they reported quantitative outcomes of the association between loneliness and suicidal experiences, including suicidal thoughts, plans, and/or attempts. Screening and data charting of the published literature was conducted by a panel of authors. The accuracy and clarity of extracted data was checked by three reviewers.

RESULTS

Among 421 articles found, 31 full texts were evaluated based on exclusion and inclusion criteria, out of which, 18 papers that reported quantitative outcomes of the association between loneliness and suicidal experiences were included. We found that association between loneliness and suicidal behaviour is determined by individual, social and cultural factors. Co-existing mental illness, substance use disorder and economic hardship play an important role for the completion of suicide.

CONCLUSION

Loneliness is correlated with suicide, and the knowledge about this association could assist in the identification of suicidal individuals or those at elevated risk of suicidal behaviour. Future studies should focus on loneliness and its relation to suicidal ideation in individuals with different mental health disorders and personalities.

Suicide hangings during pre-Covid-19 and Covid-19 - Myths debunked for the lower-middle-income group countries

The psyche about the adverse effects of the Covid-19 pandemic has got fixed to a level of conviction that committing suicide is directly linked to coronavirus infection. The statistics of suicidal hangings for the pre-Covid-19 and the Covid-19 periods were compared in the Indian capital. The data analysis of the autopsy records showed the absence of temporal association between the incidence rates of suicides between these two periods. The study concludes that there was no net increase in suicide rates in the study population of this lower-middle-income group country during the Covid-19 pandemic.

Complex Suicide: A Case Series

Suicide is a common manner of death typically carried out via a specific mechanism. When a suicidal act is committed using more than one method, it is called a complex suicide. A complex suicide can be divided into planned and unplanned. We present three cases of complex suicide in which multiple methods were used and a previous history of self-harm was present. This case series highlights the significance of a detailed medicolegal death investigation, including interviews with relatives and other witnesses, and a thorough forensic autopsy/toxicological analysis to ascertain the cause and manner of death.

Epidemiology of Suicide in Western Odisha During COVID Pandemic: A Cross-Sectional Analysis

Introduction

Suicide is the act of deliberately killing oneself. It is a leading cause of mortality worldwide. Each year, more than seven lakh people end their lives globally. India is the worst-affected country in Southeast Asia. Both the genders and all age groups are affected. The COVID pandemic has led to the disruption of routine life and business. The proportion of deaths due to suicide was 9.4% among all deaths reported for autopsies by a study in the same mortuary over a seven-year period. Increased stress and anxiety have been postulated to lead to suicide. Our study objective is to describe the epidemiology of suicide during the early COVID pandemic (lockdown period).

Methods

This is a record-based cross-sectional study. We have analyzed the post-mortem reports for six months starting from April 1, 2020. Descriptive analysis was performed with Epi Info version 7 (Centers for Disease Control and Prevention, CDC, Atlanta, GA, USA).

Results

During the study period, 340 cases were classified as deaths due to suicide, out of a total of 891 mortalities. The median age for females was 26.5 and for males, it was 30. The male to female ratio was 1.8:1. Most of the deceased (39.8%) were in their third decade, followed by the fourth decade (18.9%), second decade (15%), and fifth decade (12.98%), respectively. Poisoning was the leading method used for suicide, accounting for 238 (70.1%) deaths, followed by hanging (11.8%), burns (6.8%), jumping from a height (6.5%), and jumping in front of the train (4.13%). Self-immolation (burning) was a common mode of suicide for females. Most of the suicides (71.4%) took place from the evening to midnight.

Conclusion

There was a fourfold rise in suicides during the period compared to previous data. Productive age groups are affected more. A large-scale multi-centric study in community settings for estimation of the true burden is the need of the hour. A multi-sectorial public health approach is needed to prevent untimely death due to suicide.

A Scoping Review of Gender Differences in Suicide in India

INTRODUCTION

Much of the published literature on suicide comes from high income countries. In countries such as India, female suicide rates exceed the global suicide rate and suicide rates found in their male counterparts. Results from previous studies indicate that factors related to suicide among men and women in India are different from those seen in high-income countries. To date, no reviews have considered the relationship between gender and suicide in India. Therefore, the aim of this scoping review is to provide a comprehensive understanding of existing literature reporting gender differences in suicide rates, methods, risk factors and antecedent factors in India by reviewing published studies.

METHOD

A scoping review was conducted to map the existing literature on gender differences in suicide in India. To identify peer-reviewed publications, online databases PsycINFO and Embase were searched. The search terms were [suicid^* AND India^*]. The searches took place in November 2020 and May 2021, with no language restrictions. Articles published from 2014 onwards from India were included. Reference lists of selected studies were searched for studies that could meet the inclusion criteria.

RESULTS

This review identified 17 studies that met the inclusion criteria. The ratio between women and men who die by suicide in India is much lower than in high-income countries. Hanging was found to be a more commonly used method of suicide among both men and women, in comparison to high-income countries where hanging is more common among men. This review also identified several gaps in the literature. There were few studies that examined suicide among transgender Indians. There was limited literature on gender differences in risk and protective factors for suicide. Limitations such as the omission of a lack of gender-based analyses in several studies and under-reporting of suicide rates were identified.

CONCLUSION

Understanding suicide within the context of individual countries is essential in designing culture-appropriate suicide prevention strategies. This review identified an urgent need to establish and evaluate suicide surveillance systems in India. Furthermore, additional research is warranted to understand suicide among individuals who identify outside the gender binary, and gender-specific risk and protective factors.

Patients With Suicidal Patterns in the Emergency Room: A Clinical and Social Reflection

Background and objective Emergency physicians come across a myriad of medical afflictions resulting from suicide attempts. The Indian contribution to global suicide deaths is alarming; the social construct of India is unique, and so are the problems and challenges. This study aims to describe the social background, demographic parameters and correlate the clinical profile and outcomes of all patients presenting with an attempted or completed suicide. Materials and methods The present study is a hospital-based prospective observational study conducted by the Department of Emergency Medicine at RL Jalappa Hospital and Research Centre, a rural tertiary-care center in Karnataka, India, from June 2020 to February 2021. After stabilizing the patient, a detailed socio-demographic history was recorded. Details of the suicide attempt and findings of the clinical examination were noted. Results The final study sample consisted of 89 patients who presented to the emergency room (ER). Fifty-three patients were female, and thirty-six were males; the average age of the sample was 28.4 ± 11 years. A higher proportion of men who completed pre-university education (p= 0.0005, c2= 11.98) or had a graduate degree (p= 0.009, c2= 6.71) attempted suicide. Amongst all women who attempted suicide, 73.6% (n=39) were married at the time of the event (p= 0.0006, c2= 11.79). Poisoning (n=59) was the most common method of attempting suicide. We also observed that it was primarily men who attempted suicide when under the influence of alcohol (p= 0.006, c2= 7.57). The most common reason for attempting suicide was familial disharmony, including domestic violence. A Glasgow Coma Scale (GCS) score of 9/15 and less at the time of presentation resulted in a mortality rate of 28.6%, whereas patients with a GCS score of 10 and above had a mortality rate of 6.1% (p= 0.04, c2= 4.14). Discussion Marriage appears to be less protective for Indian women than Indian men. Poisoning was the most common method of attempted suicide in our study, followed by tablet overdose. The reason for the above could be ease of access to household poisons. Insecticides have been a preferred method in the Indian population over the years. Aluminum phosphide poisoning, a common constituent of rodenticides, is associated with a high mortality rate. However, in the West, firearm-related incidents have the highest mortality. Multiple correspondence analysis (MCA) of the National Crime Records Bureau (NCRB), India, data showed that adult males succumb majorly to romantic relations, unemployment, and failure in examinations. The use of alcohol was more in the illiterate and unskilled workers; however, high school educated persons and students used alcohol intentionally to facilitate suicide. Lower Glasgow Coma Scale values are associated with higher fatality; however, some studies found that Full Outline of Unresponsiveness (FOUR) and Acute Physiology and Chronic Health Evaluation Score (APACHE) II scores are better mortality indicators. Conclusion Besides the presentation and GCS score, cognizance of the lethality of different methods in attempting suicide provides clues in anticipating the patient's clinical course. The social patterns of suicide must be considered while designing awareness campaigns and focused outreach programs to decrease suicides. A strict policy must be made and enforced to limit the availability of household poisons.

Exploring Cross-Sectional Predictors of Suicide Ideation, Attempt, and Risk in Gender Incongruent Adults in India

INTRODUCTION

Suicide rates and suicidal tendencies among gender incongruent persons are higher compared to the general population. Yet little is known about the factors that are relevant for suicide-related outcomes among Indian gender incongruent individuals.

MATERIALS AND METHODS

Within a large sample of gender incongruent adults (n=120), we examined the contribution of demographic (age, assigned sex, gender identity, relationship, and addiction status) and socio-economic variables (education, profession, income, social support) in the prediction of three suicide-related outcomes: past-year suicidal thought, history of suicidal attempt and a composite measure of the two.

RESULTS

Of the entire sample, 25.8% (n=31) reported a past suicide attempt, with 18.3% (n = 22) reporting one attempt, 2.5% (n = 3) reporting two attempts, 1.7% (n = 2) reporting three attempts and 2.5% (n=3) reporting four to six attempts. The age at which the first suicide attempt occurs is mostly between 16 to 18 years. 19.26% (n = 21) reported that although they had not attempted suicide, they had given serious thought to killing themselves in the last year. A Chi-square test was conducted to ascertain each demographic variable and socio-economic marker. However, none of these proposed predictors correlated with suicide-related outcomes in our cohort.

CONCLUSIONS

The gender incongruent community is highly susceptible to suicidal behavior. Gender identity may be the risk factor for that behavior. Further study with larger population needs to identify other relevant risk factors, including gender-related victimization and mental health conditions as risk factors.

Study of Risk Factors Associated with Suicide Attempt in Patients with Bipolar Disorder Type I

Background  Suicide is the leading contributor to mortality in bipolar disorder (BD). A history of suicidal attempt is a robust predictive marker for future suicide attempts. Personality profiles and coping strategies are the areas of contemporary research in bipolar suicides apart from clinical and demographic risk factors. However, similar research in developing countries is rarer.

Objectives  The present study aimed to identify the risk factors associated with suicidal attempts in BD type I (BD-I).

Materials and Methods  Patients with BD-I currently in clinical remission ( N = 102) were recruited. Sociodemographic details and the clinical data were collected using a semistructured pro forma. The psychiatric diagnoses were confirmed using the Mini-International Neuropsychiatric Interview 5.0. The National Institute of Mental Health–Life Chart Methodology Clinician Retrospective Chart was used to chart the illness course. Presumptive Stressful Life Events Scale, Coping Strategies Inventory Short Form, Buss–Perry aggression questionnaire, Past Feelings and Acts of Violence, and Barratt Impulsivity scale were used to assess the patient’s stress scores, coping skills, aggression, violence, and impulsivity, respectively.

Statistical Analysis  Descriptive statistics were used for demographic details and characteristics of the illness course. Binary logistic regression analyses were performed to identify the predictors for lifetime suicide attempt in BD-I.

Results  A total of 102 patients (males = 49 and females = 53) with BD-I were included. Thirty-seven subjects (36.3%) had a history of suicide attempt. The illness course in suicide attempters more frequently had an index episode of depression, was encumbered with frequent mood episodes, especially in depression, and had a higher propensity for psychiatric comorbidities. On binary logistic regression analysis, the odds ratios (ORs) for predicting a suicide attempt were highest for positive family history of suicide (OR: 13.65, 95% confidence interval [CI]: 1.28–145.38, p = 0.030), followed by the presence of an index depressive episode (OR: 6.88, 95% CI: 1.70–27.91, p = 0.007), and lower scores on problem-focused disengagement (OR: 0.72, 95% CI: 0.56–0.92, p = 0.009).

Conclusion  BD-I patients with lifetime suicide attempt differ from non-attempters on various course-related and temperamental factors. However, an index episode depression, family history of suicide, and lower problem-focused engagement can predict lifetime suicide attempt in patients with BD-I.

The Influence of Perceived Stress and Depression on Suicide-Related Beliefs in Caucasian and Indian Adults

Abstract. Background and Aims: Suicidality research in developing countries, including India, faces logistical and cultural challenges. Technology may help address these challenges and offer data to providers treating a diverse clientele. Method: The relationship between perceived stress and suicide-related beliefs was examined in two populations: Indians in India (n = 374) and Caucasians in English-speaking countries (n = 326); the influence of depression on that relationship was also explored. The study was conducted via an Internet-based survey. Results: Three-way interactions (Ethnicity × Perceived stress × Depression status) were observed, predicting strength of the belief that suicide is a solution to problems, F(1,679) = 4.18, p < .05, and that suicide is a good option if quality of life worsens, F(1,675) = 9.53, p < .01. For both beliefs, Caucasians screening positive for depression exhibited the strongest relationship between stress and suicide-related beliefs; for Indians, that relationship was not moderated by depression status. Caucasians also exhibited a stronger association between higher stress and greater belief strength that suicide is a good option assuming a steady quality of life than did Indians, F(1,680) = 6.05, p < .05. Limitations: Participants were recruited through a depression screening website; results may not generalize to those who are uninterested in depression screening or to those who are unwilling or unable to use the internet for that purpose. Conclusion: Our findings may help to better target interventions to reduce suicidality, for example, employ stress reduction techniques for Caucasians who are depressed, and monitor suicidality for Indians reporting high stress regardless of depression.

Forensic toxicology analysis of self-poisoning suicidal deaths in Tehran, Iran; trends between 2011-2015

Background

Suicide ranks among the top ten causes of death in all age groups all over the world. There are many methods for committing suicide including self-poisoning, firearm and hanging. The aim of the present study was to provide an overview of self-poisoning related suicidal deaths with special focus on forensic toxicology analysis results in Tehran, Iran from 2011 to 2015.

Methods

All suspicious cases with the the history of self-poisoning were investigated to define the cause and manner of death under the supervision of forensic medicine practitioners. Postmortem samples were analysed in forensic toxicology laboratory to confirm the presence of drugs in cadaver of suicidal cases. Drugs and poisons were analysed using thin layer chromatography, high performance liquid chromatography, gas chromatography/mass spectrometry, headspace gas chromatography and gas chromatography equipped with nitrogen phosphorus detector. Demographic data were collected from autopsy reports of all cases with confirmed self-poisoning suicidal cause of death.

Results

Results showed that 674 cases of self-poisoning deaths were investigated during a five-year study period, of which 68.55% were male. The most often used suicide method was self-poisoning in young population. Phosphine gas liberated from aluminum phosphide tablets was the most toxic substance detected in postmortem samples (619 cases) followed by opioids, methamphetamine, organophosphates, cyanide and strychnine.

Conclusion

In conclusion self-poisoning suicidal death was predominant in young male population in Tehran, Iran. It seems that free access to suicide means such as drugs and poisons should be restricted by national and health authorities.

Trial registration

Not applicable.

Autonomic Nervous System Team-Based Learning Module

INTRODUCTION

The team-based learning (TBL) instructional strategy promotes learning and retention, enhances student engagement, allows for a deeper understanding of foundational and applied concepts, and helps students' develop lifelong learning skills. The autonomic nervous system (ANS) TBL was created for first-year medical students in the Neuroscience 1 course at Oakland University William Beaumont School of Medicine.

METHODS

The module covered the pathophysiology of ANS-related diseases and therapeutic agents that impact ANS function. By the conclusion of the module, students were able to diagnose different disease processes of the ANS, identify potential complications, and formulate appropriate management strategies. Four faculty members used backward design to create the ANS TBL. The preparatory assignment included reviewing content from previous didactic lectures and consolidating key information in provided tables. Key concepts were evaluated with readiness assurance tests. All application exercises adhered to the 4 S's.

RESULTS

Over the course of 2 years, the class averages for the individual readiness assurance test were 79.8% and 87.6%. The class averages for the team readiness assurance test and application exercises were similar across both years. Course evaluations revealed that students found the TBL relevant and valuable.

DISCUSSION

Similar TBL modules available on MedEdPORTAL are not integrated to include different aspects of the basic and clinical sciences. This ANS TBL was used to help students integrate several essential concepts, including neuroanatomy, neurophysiology, neuropharmacology, and clinical neurology. Students were very enthusiastic and engaged throughout the ANS TBL as it contained relevant case-based scenarios with questions that were meaningful for clinical practice.

Suicide in Rural Central India: Profile of Attempters of Deliberate Self Harm Presenting to Padhar Hospital in Madhya Pradesh

BACKGROUND

Suicide is a significant public health issue. India currently has the largest number of suicides in the world and has a disproportionate number of youth suicides including young women. The studies on patterns of suicide in rural central India are sparse, particularly among tribal communities.

AIMS

The aim of this study is to describe the profile of suicide attempters presenting to a secondary-level hospital in rural central India and identify areas for potential future research toward preventive strategies.

MATERIALS AND METHODS

A retrospective chart review was carried out of eighty patients who were admitted with presenting complaints of deliberate self-harm and survived until psychiatric consultation. Descriptive statistics was employed to generate the results.

RESULTS AND CONCLUSIONS

86% of the attempts were isolated impulsive attempts following triggers, the most common of which was interpersonal disputes (71%). Only 67% of patients had a mental health condition, the most common syndrome being alcohol use disorder, followed by depression, and personality disorders. Although 45% of attempters had background interpersonal conflicts, only 5% reported financial stressors as contributory. Psychosocial stressors, especially interpersonal conflicts within the family, appear to be at least as important factors as mental illnesses in contributing to suicide attempts in the area.

A descriptive study of female suicide deaths from 2005 to 2011 in Van city, Turkey

BACKGROUND

Female suicide is an important problem not only for women but for public health in general.

METHODS

Autopsy reports from the Van Chief Public Prosecutor's Office from 2005 to 2011 were reviewed retrospectively in order to analyse female deaths from suicide.

RESULTS

Sixty-six female suicide cases were recorded during 2005-2011. The mean age of the cases was 22.64 (sd = 10.09) years, and nine were below the age of 15. The most common method of suicide was hanging (44 cases, 66.7 %). Five (7.6 %) of the cases were under treatment for depression, and 12 (18.2 %) cases had a previous suicide attempt.

CONCLUSIONS

Cultural suppression of females and prevention of their socialization in enclave societies are risk factors for female suicides. The number of female suicide attempts, especially recurring attempts, should be reduced via psychiatric scanning, follow-up sessions and therapy for high-risk individuals.