INTRODUCTION

More than one lakh lives are lost every year due to suicide in India. In the last three decades
(from 1975 to 2005), the suicide rate increased by 43%. The rates were approximately the
same in 1975 and 1985; from 1985 to 1995 there was an increase of 35% and from 1995 to
2005, the increase was 5%. However, the male-female ratio has been stable at around 1.4 to
1. There is a wide variation in suicide rates within the country. The southern states of Kerala,
Karnataka, Andhra Pradesh and Tamil Nadu have a suicide rate of >15 while in the Northern
States of Punjab, Uttar Pradesh, Bihar and Jammu and Kashmir, the suicide rate is <3. This
variable pattern has been stable for the last 20 years. Higher literacy, a better reporting
system, lower external aggression, higher socioeconomic status and higher expectations are
the possible explanations for the higher suicide rates in the southern states (Vijayakumar L,
2008).[1]

Majority of the suicides (37.8%) in India are by those below the age of 30 years. The fact that
71% of suicides in India are by persons below the age of 44 years imposes a huge social,
emotional and economic burden on society.

The near equal suicide rates of young men and women and consistently narrow male:female
ratio denotes that more Indian women die by suicide than their Western counterparts.
Poisoning (34.8%), hanging (31.7%) and self-immolation (8.5%) were the common methods
used to commit suicide (accidental deaths and suicide 2007).[2] Two large epidemiological
verbal autopsy studies in rural Tamil Nadu reveal that the annual suicide rate is six to nine
times the official rates. If these figures are extrapolated it suggests that there are at least half a
million suicides in India every year. It is estimated that one in 60 persons are affected by
suicide. It includes both, those who have attempted suicide and those who have been affected
by the suicide of a close family or friend. Thus, suicide is a major public and mental health
problem which demands urgent action.

Fifty four articles on “Suicide” have been published in the IJP from 1958 to 2009. The
relative paucity in publications can be attributed to several factors but chiefly to the fact that
it is an extremely difficult area to take up for research considering its sensitive nature,
associated stigma and legal implications. It is interesting to note that the first article on
attempted suicide appeared only in 1965. The articles ranged from references to suicide in
ancient literature to psychobiological variables in suicide, epidemiological studies to
prevention strategies.

The publications have been categorized under (1) Incidence and prevalence studies (2)
Profiling and identification of risk factors (3) Suicide and suicidal behavior in specific
communities (4)Studies on Non Fatal Deliberate Self Harm (DSH) (5) Suicide prevention
strategies (6) and other, suicide related publications. The segregation is for the sake of
convenience alone and should not be seen as being exclusive to its allocated category.

There have been four studies from abroad published in the IJP that have not been covered in
the present review, these comprise of a study on women from Trinidad and Tobago, a study
from US on adolescence, on teenage suicide attempters from UK and a Japanese study on
pesticide suicides.

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INCIDENCE AND PREVALENCE STUDIES
There have been several studies reporting the incidence of suicide in India. Over the years the
studies have reported incidence rates ranging from 2.36 to 42 per 100,000 populations. The
majority of these have been hospital based studies along with a few community based
samples.

In one of the first article on attempted suicide published by the IJP, Venkoba Rao[3] reported
an incidence rate of 43 / 100,000 in Madurai. He also reported that 1 in 12 cases of suicide
attempts were fatal.

Nandi et al.[4] studied incidence rates in Bengal using data available in the public domain
across a hundred year period (1872-1972) and reported that the incidence of suicide had
increased significantly from 2.36/100,00 in 1872 to 15.96 in 1972. The study also revealed
that there was preponderance of male suicides, the vulnerable age group being those between
the ages of 18 to 30 and the most common method employed was poisoning.

Hedge[5] in his study on the patterns of suicide in a rural community in northern Karnataka
reported an incidence rate of 9.3/100,000. The study also reported a male (67%)
preponderance. The study also revealed that rural suicide patterns did not vary from urban.

In contrast to these reports Shukla et al.[6] in their study on the incidence of suicides in
Jhansi city reported more suicides among women (34 / 100,000) than men (24 / 100,000).
Several other gender related differences were also reported, women were significantly
younger (24.6 years) compared to the men (28.9 years), self immolation was the most
frequent method of suicide by women while for men it was being run over by a train.
Domestic strife and mental illness were identified as the most common causative factors. The
study reported an incidence rate of 29/100,000.

These findings were supported by Banarjee et al.[7] who studied the vulnerability of Indian
women. They found that the incidence of suicide was 43/100,000 in Bengal and that women
(79.3%) outnumbered men. 75% of the victims were below 25 years of age and the
commonest cause for suicide in women was quarrel with husband, while in men it was with
parents. Ingestion of insecticide was the most common method of committing suicide.

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PROFILING AND IDENTIFICATION OF RISK

FACTORS
Majority of the published studies on suicide have dealt with identifying the socio-
demographic and psychosocial aspects of suicide attempters and those who have completed
suicide. Some of these have also attempted to identify the characteristic differences between
the two groups. Most of these were hospital based studies. The study methods used varied,
from use of psychological autopsies to interviews to perusal of records.

Venkoba Rao[3] in his hospital based study on suicide attempts reported a preponderance of
males and identified the vulnerable age group as being those from 15 to 25 years. Lack of
social cohesion was identified as a significant risk factor. 20% of the attempters also had a
family history of mental illness/suicidal attempts. The method of attempting suicide as well
as the time (during daytime or night), were not seen as factors influencing intent.

In another hospital based study Lal and Sethi[8] reported that women attempted suicide more
often, were below 30 years of age, were housewives or domestic help, married and income
levels of 83.4% was less or equal to Rs. 200 per month. Females with lower educational level
and joint families and males with higher educational levels and from unitary families
attempted suicide more frequently. Similarly, a study by Badrinarayana[9] also revealed that
younger people (age range of 10 to 30 years) were more likely to attempt suicide. The
primary causes were identified as Mental illness and disturbed interpersonal relationships.
Extramarital affair was also identified as a risk factor for a spouse to attempt suicide by
Venkoba Rao.[10]

Nandi et al.[11] investigated the relationship between availability of lethal insecticide and the
incidence of suicide. The study concluded that there was no association between the easy
availability of the lethal insecticide and the high incidence of suicide but rather it was the
motive which actually determines the incidence of suicides.

Bagadia et al.[12] attempted to examine the relationship between unemployment and suicide
and concluded that though unemployment may be an important factor in suicide it did not
appear to be the causative factor. The study postulated that both unemployment and suicidal
behavior could be due to some common psychopathological factors. However, Srivatsava et
al.[13] (2004) identified unemployment, presence of a stressful life event in the last six
months, suffering from physical disorders and having idiopathic pain as definite risk factors
for attempting suicide.

In their study from Ludhiana, Narang et al.[14] reported that single males and married
females were more likely to attempt suicide. They, however, did not find type of family,
economic status and educational levels as being significant variables. Mood disorders and
adjustment disorders were diagnosed in a significant number of them.

Bagadia et al.[15] conducted a study on 521 patients admitted for suicidal behavior and
reported that the degree of intent was low, duration of suicidal ideas ranged from more than 1
year (2%) to it being an impulsive act in 17% of them, 18% communicated about the attempt
while the majority of women (76.1%) attempted suicide in the presence/proximity of others.
Previous attempts were reported in 7% with 2.4% having more than one previous attempt.
Depression (39.73%), schizophrenia (24.4%) and hysteria (14%) were the most common
psychiatric diagnosis made.

These findings were also confirmed by Gupta and Singh[16] who reported psychiatric
disorders in 62% with 58% having abnormal personalities. Mahla, et al.[17] investigated
attempted cases of self immolation and reported that the behavior was associated with the
presence of psychiatric and personality disorders. Jain, et al.[18] also found that 37.5% of the
suicide attempters had a diagnosis of depression, 39.28% of the subjects showed mild to
moderated suicidal intent and 16% of them had a high score on the hopelessness variable.
Similarly, in their study using the method of psychological autopsy, Khan, et al.[19]
identified the presence of psychiatric illness and stressful life events as the two most
important reasons for completing suicide.
Badrinarayana[20] found a positive and significant correlation between depressive illness,
suicidal ideation with early parental deprivation, recent bereavement and positive family
history of suicide. Similarly Srivastava and Kulshreshtha[21] reported a positive correlation
between severity of depression, being married, being employed, being male, prior history of
treatment in a mental hospital setting, more than a month’s duration of illness and age being
less than or equal to 35 years.

Anand, et al.[22] in their study on suicidal intent identified three distinct groups comprising
of non communicators (31.9%), partial communicators (32.6%) and definite communicators
(35.5%). A study by Ponnudurai et al.[23] revealed that 23.25% had contemplated suicide
earlier and that 91.9% of them were aged 30 years or less. A strong association with alcohol
was reported in 10.42% of the sample.

In his comparison study between suicide attempters and completers, Suresh Kumar,[24]
reported that those who completed suicide were significantly younger, they were more
frequently unemployed and used more lethal methods (hanging) than those who attempted.
Other variables such as religion, domicile, marital status and education showed no difference.

Very few studies pertaining to the biology of suicides have been published in the IJP. The
earliest article published was by Devi and Rao,[25] who studied the association between
suicide attempts and menstrual cycles. The study reported that women in their pre-
menstrual/early menstrual phase (64%) were more vulnerable. Marital status of the patients
did not contribute to any heightened vulnerability during premenstruum and menstruation.

Palaniappan, et al.[26] explored the possible association between suicidal ideation and
biogenic amines. They observed that the levels of 5 HIAA and Serotonin (5HT) were
inversely related to suicidal ideas. Rao and Devi[27] in their article state that evidence from
genetic research, mono amine studies and psychopharmacological research points towards a
possible biological predisposition and precipitant for suicidal behavior.