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Suicide in India: a systematic review

Article  in  Shanghai Archives of Psychiatry · April 2014

DOI: 10.3969/j.issn.1002-0829.2014.02.003 · Source: PubMed

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• 69 • Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 2

•Systematic review•

Suicide in India: a systematic review

Anil RANE1*, Abhijit NADKARNI2,3

Background: Suicide is an important cause of death in India but estimated suicide rates based on data from
India’s National Crime Records Bureau are unreliable.
Aim: Systematically review existing literature on suicide and the factors associated with suicide in India.
Methods: PubMed, PsycINFO, EMBASE, Global Health, Google Scholar and IndMED were searched using
appropriate search terms. The abstracts of relevant papers were independently examined by both authors
for possible inclusion. A standardized set of data items were abstracted from the full text of the selected
papers.
Results: Thirty-six papers met inclusion criteria for the analysis. The heterogeneity of sampling procedures
and methods of the studies made meta-analysis of the results infeasible. Verbal autopsy studies in several
rural locations in India report high suicide rates, from 82 to 95 per 100,000 population – up to 8-fold higher
than the official national suicide rates. Suicide rates are highest in persons 20 to 29 years of age. Female
suicide rates are higher than male rates in persons under 30 years of age but the opposite is true in those
30 years of age or older. Hanging and ingestion of organophosphate pesticides are the most common
methods of suicide. Among women, self-immolation is also a relatively common method of suicide. Low
socioeconomic status, mental illness (especially alcohol misuse) and inter-personal difficulties are the
factors that are most closely associated with suicide.
Conclusion: The quality of the information about suicide in India is quite limited, but it is clearly an
important and growing public health problem. Compared to suicides in high-income countries, suicide in
India is more prevalent in women (particularly young women), is much more likely to involve ingestion of
pesticides, is more closely associated with poverty, and is less closely associated with mental illness.

Key words: suicide, India, systematic review, organophosphate pesticide, mental illness

1. Introduction specific analyses are needed to develop targeted suicide

Suicide is the final outcome of complex interactions prevention efforts.
of biological, genetic, psychological, sociological and The World Health Organization (WHO) estimates
environmental factors. It is an increasingly important that of the nearly 900,000 people who die from suicide
public health issue: from 1990 to 2010 the number globally every year, 170,000 are from India.[3] However,
of global suicides increased by 32%. It is particularly India’s National Crime Records Bureau (NCRB) – which
important among young adults 15 to 49 years of age report official suicide rates based on police reports –
among whom it accounts for 4.8% of all female deaths estimated only 135,000 suicides in 2011.[4,5] One possible
and 5.7% of all male deaths. [1] Eighty-four percent reason for under-reporting of suicide by the NCRB is that
of global suicides occur in low and middle-income suicide remains a crime in India.[6] Detailed independent
countries (LMICs); India and China alone account for verbal autopsy investigations of all unnatural deaths in
49% of global suicides.[2] There is substantial variability several rural areas of the country report suicide rates
both in the prevalence of suicide and in the factors that are up to five-fold higher than the official national
that influence the occurrence of suicide between average.[7] Despite the importance of suicide both as
geographic regions, cultures, and over time, so country- a health problem and as a social problem, the issue

doi: http://dx.doi.org/10.3969/j.issn.1002-0829.2014.02.003
1
Institute of Psychiatry & Human Behaviour, Goa, India
2
London School of Hygiene & Tropical Medicine, London, United Kingdom
3
Sangath, Goa, India
* correspondence: [email protected]

A full-text Chinese translation will be available at www.saponline.org on May 15, 2014.

Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 2 • 70 •

receives little attention from Indian policy makers. This were identified. The screening and selection of papers
neglect of the issue is reinforced by cultural influences, was independently conducted by both authors; in the
religious sanctions, stigmatization of the mentally ill, cases where different papers were selected the paper
competing political imperatives, and socio-economic was re-assessed and discussed by both authors to arrive
factors.[8] at a consensus decision.
This systematic review aims to provide a more We extracted the following data from included
balanced assessment of the prevalence and correlates papers: date of publication, study design, setting, center
of suicide in India by identifying and integrating all (state, city), methods, sampling technique, sample
available reports on the subject. size, definition of suicide, prevalence, and correlates of
suicide. Data extraction was conducted by one reviewer
(AR). We present the results as prevalence rates
2. Methods and, where available, corresponding 95% confidence
We searched the following electronic databases: intervals (CI).
PubMed, PsycINFO, EMBASE, Global Health, Google
Scholar and IndMED (database of articles published in
Indian biomedical journals). The combination of search 3. Results
terms (in the title or abstract fields) used included The selection of included articles is shown in Figure 1.
‘suicide’ OR ‘suicidal’ OR ‘suicidality’ OR ‘hanging’ OR Thirty-six papers were selected for the review, of which
‘drowning’ OR ‘self-poisoning’ OR ‘overdose’ OR ‘self- 6 were published between 1971 and 1980, 3 between
injury’ AND ‘India’ OR ‘Indian’. The titles of the papers 1981 and 1990, 3 between 1991 and 2000, and 24
identified through the database search were screened between 2001 and 2010. Thirty papers were about cross
and the abstracts of papers that reported on suicide sectional surveys, 3 were case control studies and 3
or self-harm in India were retrieved. These abstracts were ecological studies. Details of the studies are shown
were examined and the full text of papers that reported in Table 1. The studies were conducted in different parts
on the prevalence or correlates of suicide or self-harm of the country and used different sampling strategies
were retrieved. These full texts were then examined and settings. Most studies either used verbal autopsy
to determine their compliance with the following (i.e., interviewing family informants and other associates
eligibility criteria: papers published prior to June 2012 of the deceased) or the integration of multiple sources
that reported the prevalence or correlates of suicide in of information about a death to determine whether
any part of India for either gender in any age group. The or not a death should be classified as a suicide –
reference lists of selected papers were hand-searched methods that are generally considered to be reliable.
for additional eligible papers, but no additional papers Some studies were part of ongoing community-based
surveillance efforts that provided population based
rates; but other studies did not specify their sampling
Figure 1. Flowchart of identification of articles strategies or had non-random sampling designs, making
it difficult to assess the validity of the reported results.
3277 articles published before June 2012 were
identified from PubMed, PsycINFO, EMBASE, Global 3.1 Prevalence of suicide
Health, Google Scholar and IndMED using the
following search terms (in the title or abstract): A community-based surveillance system using verbal
‘suicide’ OR ‘suicidal’ OR ‘suicidality’ OR ‘hanging’ autopsy covering a population of 108,000 in a rural
OR ‘drowning’ OR ‘self-poisoning’ OR ‘overdose’ OR development block of Tamil Nadu (one of the more
‘self-injury’ AND ‘India’ OR ‘Indian’ highly developed states in southern India) has been
operating for several decades.[22,26,33,35,36] Several reports
1028 duplicate reports excluded have appeared using these data. The prevalence of
suicide for the period from 1994 to 1999 was 95 per
The titles of the 2249 articles were screened 100,000 population (annual rates ranged from 84 to 106
per 100,000) accounting for 8 to 12% of all deaths.[23]
From 2000 to 2002 the average suicide rate was 92 per
2148 reports excluded 100,000 (112 in men and 72 in women) accounting for
9.8 to 11.4% of all deaths.[36] For the period from 1998
The full text of 101 articles were examined to to 2004 the average suicide rate was 82 per 100,000.[35]
determine whether or not they reported on the In young people 10 to 19 years of age, over the 10-year
prevalence or correlates of suicide in India period from 1992 to 2001 the average male suicide rate
was 58 per 100,000 (accounting for 25% of all deaths)
65 reports excluded and the average suicide rate for women was 148 per
100,000 (accounting for 50 to 75% of all deaths).[26]
36 articles included in qualitative synthesis Over the same 10-year period, the mean suicide rate in
persons 55 years of age or older was 189 per 100,000.[33]
• 71 • Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 2

Table 1. Description of reviewed studies

Author (Year) Design Sample Prevalence Correlates of suicide Method of suicide
Sathyawati[9] CSS 45 suicides in Increase in suicide rate with Burning and drowning
(1975) legal children (<14 age; 76% girls; 38% working each accounted for
records years) in a large as laborers, domestic servants 38%; poisoning 3%;
city from 1967- or errand boys; 80% live with and hanging 9%.
1973 parents; 75% had clear social
stressors.
Nandi[10] National Comparison Suicide rate was In 1872 most suicides occurred Poisoning (44%) and
(1978) mortality of registered 2.4 per 100,000 between ages 25 and 30, and in hanging (41%) in 1872;
records, suicides in 1872 in 1872 and 16.0 1972 most suicides occurred in poisoning (50%) and
WHO and 1972 in per 100,000 in the 18 to 30 age group. Men had hanging (22%) in 1972.
reports Bengal. 1972. higher rates at both times.
Sharma[11] CSS 130 suicides Majority 25 to 44 years of age;
(1978) legal reported in a 63% males; 88% living in joint
records single community families; 70% of males and 63%
from 1968 to of females married; 15% had
1970 mental illness; 22% had prior
domestic conflict.
Nandi[12] CSS All suicide cases Prevalence of Most suicides were in the 15 to In 1976 67% of suicides
(1979) legal reported in two suicide was 28.6 24 age group. In one village male ingested Endrine and
records village police per 100,000 in suicide was rare (none in 1976 22% died by hanging.
stations from one village and and only 1 in 1977); in the other In 1977 (after a ban
January 1976 to 5.1 per 100,000 the male-to-female suicide ratio on Endrine) 50% used
September 1977. in the other. was 1 in 1976 and 0.4 in 1977. Endrine and 32% die
Chronic or incurable illnesses and by hanging
domestic conflict were common
precipitants of suicide.
Hedge[13] CSS 51 suicides 9.3 suicides per Most suicides were in the 10 to Drowning 39%,
(1980) legal recorded over 9 100,000 per 29 age group. Males 67%. Marital poisoning 33%,
records years in a cluster year. and domestic problems 37.3%, hanging 25%, other
of villages with incurable disease 29%, and methods 2%.
a population of financial problems 10%.
61,561.
Ponnudurai[14] CSS 87 suicides Males 44.8%. Married women Most common method
(1980) legal recorded at an below 30 years of age at high risk; was hanging followed
records urban police marriage in males not associated by organophosphate
station in 1978. with suicide; mental illnesses in pesticides in males and
7.6% males and 12.5% females. drowning in females.
Gupta[15] CSS 180 fatal burns 23.9% of fatal 94% self-immolation suicides
(1988) autopsy cases reported burns were were female; 85% of females
records to a district suicides. were married; among married
mortuary in a females 73% of were married
one-year period. in last 5 years, 51% tortured
by husband/in-laws for dowry,
and 32.5% occurred following a
quarrel or marital disharmony.
Banerjee[16] CSS 58 suicides in one 43.4 per Quarrel with a spouse was a Insecticide poisoning
(1990) semi year based on 100,000 per common cause for suicide in was most common
structured police records in a year. females (32%) and quarrel with method (93%)
interview cluster of villages parents in males (33%).
with a population
of 133,510
Shukla[17] CSS 187 urban Annual rate of Poisoning (22.6%),
(1990) legal suicides identified suicide was 29 burning (21.4%),
records in police records per 100,000. drowning (20.3%),
from 1986 to hanging (18.7%) and
1987 in a city getting run over by
car/train (13.3%) were
reported.
Ponnudurai[18] CSSa, 144 consecutive 34% of males preferred places
(1997) autopsy suicide autopsies outside their houses for suicide:
and legal over one year in hotel rooms (7.9%), rivers (6.7%)
records a tertiary care and work place (4.5%). Other
hospital. sites were railway station, park
and water tank.
Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 2 • 72 •

Table 1. Description of reviewed studies (continued)

Author (Year) Design Sample Prevalence Correlates of suicide Method of suicide
Vijaykumar[19] VA 100 urban suicides, Factors with increased odds of
(1999) CCS 100 neighborhood suicide: presence of DSM-III-R
legal age and sex matched Axis I disorder, family history of
records controls psychopathology and life events
in the month before suicide.
Bhatia[20] CSS 55 suicide cases Majority married, high school Hanging (43.6%),
(2000) referred for post educated; 18.2% had made prior burning (38.3%),
mortem evaluation at attempt. poisoning (12.7%)
a tertiary care center.
Mayer[21] Ecological Suicide data released Suicide rates In India the classic suicide sex
(2002) study, by the NCRB for the increased ratio is inverted for the ‘≤14’-
analysis years 1991 to 1997 between 1991 and ’15 to 29’ year age groups.
of data and 1997 from Peak for male suicides is in the
from 9.2 to 10.0 per 30 to 59 age group, for women is
NCRB 100,000 in the 15 to 29 age group.
Batra[22] CSS 942 autopsies due to 15.1 per 48% of fatal burns are suicidal;
(2003) autopsy burns in a rural health 100,000 deaths 75% of cases from rural districts;
and legal district over 5 years by burns per 21 to 30 age group most
records year affected; females accounted for
81%; torment by in-laws was
common cause (32%).
Joseph[23] CSS Suicide registry in Suicides M:F ratio was 1.2:1; rates higher Poisoning (45%) and
(2003) VA rural development accounted 8 in older men than older women; hanging (41%) were
block with a to 12% of total but in 15-24 age range rate the most common
population of 108,000 deaths; mean higher in women (102/278) than methods.
from 1994 to 1999 suicide rate in men (58/331).
95/100,000.
Sharma[24] CSS 857 suicides in 2272 38% of Most common in the 15 to 30 Poisoning (18%),
(2003) autopsy autopsy records from autopsies were age group; majority male; most self-immolation
records January 1994 to suicide deaths from rural communities; 40% (16%) and hanging
December 2001. had social difficulties, 28% had (3%) were most
guilt or shame, and 15% had a common methods.
recent loss.
Steen[25] Ecological Data on suicide from Human development factors
(2003) study NCRB did predict suicide rates in
both genders but no significant
relationship between suicide
rates and economic factors.
Aaron[26] CSS 154 male and 152 Average suicide Family conflicts, domestic Hanging (44%),
(2004) VA female suicide (10 to rate in young violence, academic failures, poisoning with
19 year olds) in a rural women 148 per unfulfilled romantic ideals, and insecticide (40%),
development area 100,000 and in mental illness were main causes. self-immolation
with total population young men 58 (9%), and drowning
of 108,000. per 100,000. (7%).
Girdhar[27] CSS Post-mortems of 38 of 50 notes written by
(2004) suicide 50 suicidal deaths males; note writers had higher
note with suicide notes education but otherwise did
study compared to 50 not differ greatly from non-
without notes from note writers; most frequent
total of 320 suicide reported reasons were physical
post-mortems done and psychiatric illness; 13 note-
over 1.5 years at a writers did not mention any
tertiary center. difficulty.
Gururaj[28] VA 269 suicide cases M:F ratio was 2:1; 75% in 16 to Hanging (59%),
(2004) CCS identified from police 49 age group; emotional abuse poisoning (25%)
records (over a (OR=2.6), physical violence and self-immolation
3-month period) and (OR=1.8), longstanding alcohol (11.5%) were
269 age- and gender- abuse (OR=4.8), absence of social common methods;
matched controls support networks (OR=3.1), burns (self-
from a city of 6 million limited resources (OR=11.5) immolation) twice
and presence of mental illness more frequent
(OR=1.6) were significant factors. among women than
men.
• 73 • Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 2

Table 1. Description of reviewed studies (continued)

Author (Year) Design Sample Prevalence Correlates of suicide Method of suicide
Kumar[29] CCS 689 autopsies of 61.8% males, older and likely to Hanging (48.2%),
(2004) case suicide victims be employed. poisoning (28.9%),
records during January to and immolation
December 2001 (12.8%, 6 times more
common in females
than males).
Lalwani[30] CSS 222 autopsies of 1.9% of all Girls 55.4%; the most common Hanging (girls 57%,
(2004) autopsy suicidal deaths in 10 autopsies in 10 age was 15 to 18 years. boys 50%); poisoning
records to 18 year olds at a to 18 year olds (girls 37%, boys
tertiary care center were suicides. 50%).
over 10 years
Sharma[31] CSS 2835 autopsies of 39% of Suicide was most common in Poisoning (48%),
(2004) autopsy unnatural deaths unnatural the 21 to 30 age group; male-to- burns (40%) and
records over 10 years from deaths were female ratio was 2:1; majority hanging (10%).
1994 to 2003 at a suicidal from rural background.
tertiary care center.
Steen[32] Time Available data on The differences As modernization increases, there
(2004) series completed suicides between male is little change in the male-to-
analysis, in all Indian states and female female suicide ratio.
NCRB from 1967 to 1997. suicide rates
reports were relatively
stable over the
30 year period.
Abraham[33] CSS 152 male and 100 Annual suicide Male-to-female ratio was 1.5:1; Hanging (51.6%) and
(2005) VA female suicides in rate for people suicide rate increased with age. poisoning (38.9%)
persons 55 years or over 55 years were most common
older over 8 years in was 189 per methods; women
a rural development 100,000. more likely to use
area with total burning or drowning.
population of
108,000.
Khan[34] CSS 50 suicide cases Urban 72%; low income 54%; Hanging common
(2005) VA referred for autopsy 24% had consulted physician or in males, self-
at a tertiary center. psychiatrist, 94% had stressful immolation in
life events; precipitating factors females.
present in 84%.
Bose[35] CSS 638 suicides over 82.2 per Hanging (47.8%), use
(2006) VA 7 years in a rural 100,000 of poison (40.4%),
development area population, burning (7.2%),
of 108,000 11.3% of all drowning (4%).
deaths.
Prasad[36] CSS Suicides in a rural 92 per 100,000; Male-to-female ratio was 1.5:1; Organophosphate
(2006) VA development block accounts for suicide rate for men increased pesticides (40.5%)
with population of 9.8 to 11.4 % with age; women peaks in and hanging (49%)
108,000 from 2000 of all deaths; young and old; more suicides were the most
to 2002 rates in men in younger women than men; common methods.
and women 77% had chronic stress; 23% had
were 112 and acute precipitating events; men
72 per 100,000, and those 44 or older had more
respectively. chronic stress whereas women
and those under 44 had more
acute precipitating events.
Mohanty[37] CSS 588 deaths 11.8 suicides Male-to-female ratio almost Hanging (32.6%),
(2007) Interview, diagnosed as per 100,000 equal; 21-30 years was the most poisoning (30.6%).
case suicidal among population; common age group; rural areas
records 2096 autopsies over 28% of (50%); married (71%); unsound
and 4 years at a tertiary autopsies were mind (6%); past suicidal tendency
autopsy center. suicides. (14%); intake of alcohol (22%);
findings financial burden (37%); and
marital disharmony (35%).
Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 2 • 74 •

Table 1. Description of reviewed studies (continued)

Author (Year) Design Sample Prevalence Correlates of suicide Method of suicide
Chavan[38] CSS 101 deaths by 60% were between 20 to 29 years Hanging (72%);
(2008) VA suicide in a city in old; males (57.4%), unemployed poisoning (16%).
2003. (55.4%), unmarried (57.4%), urban
residence (70.2%), and low income
(50.4%); psychosocial stressors
(60.3%), interpersonal stressors
(47.5%), and financial stressors
(8.9%); psychiatric illness (34%);
alcohol or substance abuse in
(24%).
Gupta[39] CSS 8 cases of murder- All assailants were mothers and all Methods either for
(2008) legal suicide from 2000 victims were their children aged 6 killing or suicide were
records to 2004. months to 7 years; five incidents in either burning or
rural areas, three in urban areas; drowning.
all cases in low socio-economic
families; main cause is family-
related problems.
Kanchan[40] CSS Retrospective 5 18% of all Male 74%; most in the 20 to 29 age Agrochemicals
(2008) legal and years post mortem autopsies group; highest female rates during were the preferred
autopsy studies of 137 were deaths 2nd, 3rd and 6th decade; highest agents, especially
records suicidal poisonings due to suicidal male rates in 4th, 5th, and 7th organophosphates.
at a tertiary center. poisoning. decade; 28% of female and 11% of
male suicides had depression.
Bastia[41] CSS 104 consecutive Marriage protective for men Hanging (15.7%),
(2009) VA autopsies of death (OR=0.14, CI=0.06–0.36); risk insecticide-ingestion
by hanging over factors included dowry dispute, (37.2%), other
a 2-year period unemployment, illicit relationship
substance use (13.4%);
reported at a of spouse and prolonged illness.medication overdose
Medical College. (6.5%), jumping under
train (9.2%) and, self-
immolation 8.5%.
Parkar[42] CSS 76 families of Most common age group was 21 Common methods
(2009) EMIC suicide decedents to 28 years old; more women in were burning (56.6%),
Interview identified from young age groups and more men in poisoning (18.4%) and
with police record in an older age groups; women had less hanging (15.8%).
family of urban slum from education; 36% had prior attempts;
suicide 1997 to 2003. common stressors included
victim substance use by self or others,
failed expectations, financial loss,
interpersonal conflict and verbal
abuse.
Soman[43] CSS Deaths over 5 6.6% of all Hanging (64%),
(2009) VA years in seven deaths were poisoning (10%),
contiguous districts suicidal; male drowning (9.3%), self-
constituting a rate was 45 immolation/burning
development per 100,000, (6.4%), and jumping in
block in a southern accounting front of train (6.4%).
state (798,695 for 7.3% of
person years of all deaths;
observation). female rate 27
per 100,000,
accounting
for 5.8% of all
deaths
Manoranjit- CCS 122 family Male-to-female ratio was 1.5:1;
ham[44] VA members of 37% of the suicides and 16% of
(2010) suicide cases controls had at least one Axis I
and 100 age and diagnosis; among suicides a higher
gender matched proportion lived alone, experienced
controls in a rural termination of a steady
and suburban relationship, felt on-going stress,
population. had few confidants, were widowed
or separated, or experienced
chronic pain.
CSS, Cross-sectional study; VA, Verbal autopsy; CCA, Case-control study; NCRB, National crime-records bureau
• 75 • Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 2

A prospective community-based cohort study also found that suicide rates increase with age,[9,30] with
of cause of death in the south Indian state of Kerala the highest rate in the oldest children (i.e., those 15 to
from July 2002 to June 2007 reported a male suicide 18 years of age).
rate of 45 per 100,000 and a female suicide rate of 27 Age related trends differ by gender. The mean (sd) age
per 100,000, which collectively accounted for 6.6% of of suicides as reported by Bastia and colleagues in 2009
all deaths.[43] A retrospective, 4-year autopsy-based was 32.5 (13.6) in males and 25.9 (8.7) in females.[41] Other
study by Mohanty and colleagues reported a suicide studies have also reported higher mean age among male
prevalence of 12 per 100,000 population. [37] Other versus female suicide decedents (28.9 [12.6] v. 24.6 [10.5];
autopsy studies[24,27,31,37] with sample sizes ranging from p<0.02).[17] In the community-based surveillance study
2096 to 2835 report that the proportion of suicidal in rural Tamil Nadu, the suicide rate for men increased
deaths among all autopsies ranged from 28 to 39%. A with age while the suicide rate for women had two
large (n=11,583), 10-year retrospective autopsy study peaks, one between 15 and 24 years of age and the
published in 2004 by Lalwani and colleagues reported other over 65 years old.[36] Several studies have reported
that 1.9% of all autopsies were suicides in individuals higher suicide rates among younger women than
10 to 18 years of age.[30] An earlier 7-year autopsy study younger men and higher suicide rates among older men
reported in 1975 by Sathyawati and colleagues reported than among older women.[14,21-23,25,40-42] A prospective
that among 1834 autopsies of suicide decedents, 45 5-year cohort study reported that the age-specific male
(2.4%) were children 14 years of age or younger.[9] to female ratio of suicide rates ranged from 0.4 in the
youngest age group (i.e. 0 to 14 years) to 4.5 in the 45 to
3.2 Methods of suicide 54 age group.[43]
Hanging was the most frequently reported method of
suicide in most of the studies, accounting for 10 to 72% 3.3.2 Gender
of all suicides.[13,14,17,19,20,26, 28,29,31,33-35,37,38,42,43] The second The evidence for differences in the rate of suicide by
most frequently reported method was self-poisoning gender is inconsistent. Some studies report that a higher
(often ingestions of organophosphate pesticides), which proportion of suicides are male (57 to 74%)[11,13,20,31,36,38,40]
accounted for 16 to 49% of all suicides.[13,16,17, 19,26, 28,29,31,33- while others report that a higher proportion of suicides
35,37,38, 42,43]
The proportion of all suicides attributed to are female (56 to 79%). [14,16,41] Still other studies
drowning ranged from 3 to 39%[13,17,19,26,35,43] and the report that there is no significant difference in the
proportion attributed to burning or self-immolation proportion of suicides by gender.[37] Reports based on
ranged from 6 to 57%. [17,19,26,28,29,31,34,35,38,42,43] Other the community surveillance data in Tamil Nadu indicate
reported methods of suicide include jumping off heights that the male-to-female gender ratio (combining all age
(0.5 to 2% of all suicides),[17,19,38] being run over by a train groups) has been stable over the last 30 years, ranging
(6 to 13% of all suicides)[17,43] and using a firearm (3% of from 1.3:1 to 1.5:1 (i.e., an excess of males).[21,32,36] As
all suicides).[17] discussed above, the male-to-female gender ratio of
Some studies report gender-based differences in suicide rates is lower than 1 (i.e., a predominance of
method preference. A community-based surveillance females) in the young age groups and greater than 1 (i.e.,
study by Prasad and colleagues reported in 2006 a predominance of males) in the middle and older age
found that significantly more women chose drowning groups.
and burning as modes of suicide than men, while
significantly more men chose hanging. [36] A similar 3.3.3 Marital status
pattern of gender-based method preference was
reported by Abraham and colleagues among persons Most studies report that the majority of suicide
55 years of age and older.[33] Other studies report higher decedents were married at the time of death (57 to
rates of suicides by hanging in males than females,[17,34,42] 73%),[11,17, 20,24,37,41,44] but two studies reported that a
a predominance of males in suicide decedents who use higher proportion of suicide decedents were unmarried
other violent methods[17,34] (e.g., jumping in front of a (52 to 58%).[34,38] In one prospective study of suicide
train), and a predominance of females among suicides autopsies, male suicide decedents were more likely
by self-immolation.[17,33] to be single (60.5%) while female suicide decedents
were more likely to be married (73.8%); marriage was
protective in males (OR=0.1, 95% CI=0.1–0.4), but
3.3 Correlates of suicide not in females.[41] In a case series of suicidal deaths,
being married put women – particularly women under
3.3.1 Age 30 years of age – at a higher risk of suicide, but this
Suicides in the third decade of life (i.e., in persons 20 to was not the case for men.[14] One case control study
29 years of age) account for 41 to 62% of all suicides. found a much higher risk of suicide in persons who are
[13,16,17,28,31,34,37,38,42]
Among older adults, the age-specific widowed, separated or divorced compared to persons
suicide rate increases with age: it is 137 per 100,000 who are currently married (13% v. 1%; p=0.003)[19]; this
for persons 55 to 64 years of age, 204 for persons 65 to finding was supported by another study that found that
74 years of age, and 331 for persons 75 years of age or being separated or widowed was significantly associated
older.[33] Studies among children under 18 years of age with suicide (OR=2.9, 95% CI=1.1-7.7).[44]
Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 2 • 76 •

3.3.4 Education networks (3.1, 95% CI 1.1-8.5) and limited resources

Evidence for the association of education and suicide is (11.5, 95% CI 4.6-28.8) were independent risk factors for
inconsistent. In one study, individuals who were illiterate suicide. Factors considered in the study that were not
or less educated were at significantly higher risk of significantly associated with suicide included presence
suicide (χ2=44.33, p<0.001),[37] a finding that was also of a mental illness (1.6, 95% CI 0.4-2.5), emotional abuse
reported in two studies that had female-only samples.[17,42] (2.6, 95% CI 0.1-56.2) and prior experience of physical
However, a psychological autopsy study reported that a violence (1.8, 95% CI 0.4-8.1).[28] Another multivariate
larger proportion of subjects had completed high school analysis[44] identified on-going stress (odds ratio=97.7,
(33%) or college (25%).[38] 95% CI 27.8-3343.2) and chronic pain (66.1; 95% CI 5.0-
873.5) as important risk factors for suicide.
3.3.5 Occupation
The association of occupation to suicide is also incon- 3.3.9 Mental illness
sistent. In a psychological autopsy of suicides, 55% The prevalence of any psychiatric illness among
were unemployed and a further 40% were semiskilled suicide decedents varied based on the source of the
workers.[38] In a community based study, most of the data: psychological autopsy studies reported a 34%
women who completed suicide (54%) were house- prevalence of mental disorders in suicide decedents,
wives.[42] In a study of suicides among children (i.e., case series studies reported a prevalence of 24% and
under 14 years of age), 38% were working as daily wage studies based on police records reported a prevalence
laborers, domestic servants or errand boys.[9] ranging from 5 to 25%.[11,14,22,37,38,40]
Several studies found that the presence of a
3.3.6 Socioeconomic status (SES) current mental disorder increased the risk of suicide
(odds ratios range from 3.1 to 19.5).[19,28,44] Several
There are fairly consistent reports of higher suicide rates specific conditions were associated with elevated risk
in persons of low SES. Low SES was reported in 50 to for suicide: alcohol consumption (odds ratio=4.5, 95%
66% of suicide victims.[34,38,42,44] A case control study[28] CI=3.0-6.8), a history of chronic alcohol abuse in self
reported that 35% of suicides occurred in households (23.4, 95% CI=12.9-43.7), a history of chronic alcohol
with monthly incomes of less than 3000 rupees (about abuse in one’s spouse (6.1, 95% CI=2.5-15.4),[28] alcohol
50 $US) and another 35% occurred in households dependence (2.8, 95% CI=1.0-6.8), adjustment disorders
with incomes of 3001 to 6000 rupees (50 to 100 $US). (3.4, 95% CI=1.2-9.6)[44] and personality disorder (9.5,
Another control study reported that low socio-economic 95% CI=2.3-84.1).[19]
status was an independent risk factor for suicide.[37]

4. Discussion
3.3.7 Residence
In a psychological autopsy study in the city of Understanding a complex phenomenon like suicide in
Chandīgarh, 70% of the identified suicide decedents a country as diverse as India through studies of varying
were from an urban background, 10% were from rural strengths and limitations is quite a challenge. As of
areas, and 20% from suburban areas.[38] In this study, June 2012 we could not find a single pan-India study
57% of the identified suicide decedents had migrated investigating the prevalence or correlates of suicide. The
from other parts of India and abroad. One study sampling strategies and methodologies of the 36 studies
reported that 50% of suicide decedents were from rural we identified were quite heterogeneous so it was not
areas,[37] and another reported a rural-to-urban ratio of possible to conduct a meta-analysis that would integrate
suicide decedents of 1.4:1.[24] the findings.
There are, however, some trends that emerge
from this qualitative review of the available literature.
3.3.8 Psychological stressors Suicides in India are largely under-reported; the rates
The common stressors associated with suicides included reported in the papers identified for this review are
interpersonal difficulties (especially conflicts with spouse likely to be underestimates. Hanging and self-poisoning,
or other family members),[11,13,16,22,26,27,37,38,42] psychosocial especially with organophosphate pesticides, are
stress, [11,24,26,27,38,42] financial problems, [11,13,22,27,37,38,42] the most common methods of suicide. The young,
chronic illnesses,[11,13,22,27,41] domestic violence,[22,26,41,42] particularly young women are at a high risk of suicide.
work-related problems, [11,27,38,41,42] extramarital Low socioeconomic status, interpersonal stressors
relationships, [11,22,41] legal problems, [38] academic and the presence of mental illness are important risk
difficulties, [26,27] living alone, [44] and other types of factors for suicide. There is insufficient evidence to draw
stressful life events.[19,28,34,44] conclusions about the importance of education, marital
One multivariate analysis of the independent role status, residence or employment status as potential risk
of various psychosocial stressors as risk factors for factors for suicide.
suicide [28] reported that longstanding alcohol abuse (odds Based on results of a nationally representative
ratio=4.8, 95% CI 1.9-12.8), absence of social support mortality survey implemented by the Registrar General
• 77 • Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 2

of India between 2001 and 2003, the estimated rate female suicides than males suicides).[53] The higher rates
of suicide in persons 15 years of age or older in 2010 of female suicide in Asian countries may be linked to
was 22 per 100,000 population, accounting for 3% of the position of women in the traditionally patriarchal
all deaths in persons 15 or older.[6] Large scale verbal societies of Asia. Niaz and Hassan[54] argue that “women’s
autopsy studies of all deaths find that the suicide rates lack of empowerment and both financial and emotional
in rural areas are three- to four-fold higher than those dependence have restricted their self-expression and
reported by the government.[45] The reported annual choices in life. This, along with family, social and work
rates of suicide per 100,000 population by the NCRB pressures, has a definite impact on women’s mental
from 2008 through 2012 were 10.8, 10.9, 11.4, 11.2 and health.”
11.2, respectively.[46] These official government figures Though not unequivocal, our review found that
– which are about half those identified in the Registrar female suicide decedents were more likely to be
General mortality study – clearly underestimate the married and male suicide decedents were more likely
magnitude of the problem. The stigma associated with to be single. The peak in the suicide rates for females
suicide and the criminalization of suicides under Indian was in the 15 to 29 age group, which coincides with
law both deter reporting, and, thus, lead to serious the traditional age for marriage for Indian females.
under-estimation of the suicide rate. Cultural attitudes toward the woman’s role in marriage
The availability of specific means for suicide affects may partially explain the comparatively higher ratio
national patterns of suicide methods. In the United of female to male suicides found in Asian countries
States, firearms are used in most suicides[47] while in compared to those in Europe and the United States.
countries with large rural populations such as China and In countries like India, Pakistan and Sri Lanka where
the Republic of Korea pesticides are the most common arranged marriages are common, the social and familial
method.[35,48] In Australia, Japan, New Zealand, Pakistan, pressure on a woman to stay married even in abusive
and Thailand, hanging dominates while in Hong Kong relationships may be one of the factors that increases
and Singapore, jumping (typically from tall apartment the risk of suicide in women.[28] Dowry-related suicides
buildings) is the most frequent method used.[49,50] Our are not uncommon in India; when dowry expectations
review found that hanging was the most common are not met young brides can be harassed to the point
method of suicide in India closely followed by self- where they are driven to suicide.[55]
poisoning, especially with organophosphate pesticides. The data related to the potential role of educational
In the Registrar General mortality study about half of status as a risk factor for suicide identified in the
suicide deaths were due to poisoning (mainly ingestions review was ambiguous so no clear correlation could be
of pesticides) and hanging was the second most established. However, the evidence about a relationship
common method.[6] The Registrar General study also between low socioeconomic status and suicide was
reported that burning (self-immolation) was a relatively more robust. India is experiencing rapid socio-economic
common method of suicide in women, accounting for changes and a related widening of the gulf between the
one-sixth of all female suicides.[6] India has the dubious rich and the poor. In both high-income and low- and
distinction of having the highest absolute number of middle-income countries suicide rates tend to be higher
self-immolation cases, the highest fatality rate from in the subgroups of the population that are unable
self-immolation, and the highest proportion of hospital to realize the aspirations engendered by economic
admissions for burns that are due to self-immolation.[51] prosperity, those who remain in chronic poverty,
Our review clearly indicates that the young in India unemployment and debt.[28,45,56,57,58]
are at a high risk of suicide, a finding that is consistent The available studies do not provide a definitive
with the Registrar General mortality study and the NCRB answer about the relationship of location of residence
data.[4,6] In the Registrar General mortality survey, 40% and suicide, but there do appear to be higher suicide
of suicide deaths in men and 56% in women occurred rates in rural versus urban areas both in India and in
between the ages of 15 and 29. A 15-year-old individual other countries with large agricultural populations.[4,6,45]
in India had a cumulative risk of 1.3% of dying by suicide If true, the likely explanations for the higher suicide
before the age of 80.[6] rates in rural areas would include rapid migration,
Although our review could not demonstrate a economic hardship, lack of social support, isolation,
clear gender difference in risk for suicide, many of the relatively easy access to lethal means (e.g., pesticides)
reviewed studies reported an overall male excess when and the lack of high-quality resuscitation services.[45,59]
combining suicides across all age groups. However, Interpersonal conflicts, particularly those with
several of the studies also reported a higher prevalence family members, were the most common type of
of suicide in females than males in the younger age stressors associated with suicide identified in the
groups. This gender difference is in keeping with that studies considered in this review. Asian countries have
seen in other Asian countries. Unlike in most European traditionally been characterized by the centrality of
countries and the United States, where male suicides extended family systems, dependence on the family,
far outnumber female suicides (3:1 to 4:1),[52] in most and the subjugation of individual concerns to the needs
Asian countries the ratio is much lower, and in China of the family. However, rapid economic development,
the ratio actually falls below 1:1 (i.e., there are more social transformation and globalization are changing
Shanghai Archives of Psychiatry, 2014, Vol. 26, No. 2 • 78 •

the role of the family and the relationships between stronger predictors of suicidal behavior than affective
the individual and the family in many of these disorders.[65]
countries. These changes are engendering new types
of interpersonal conflicts as traditional expectations of
families encounter modern aspirations of individuals. 5. Conclusion
As just one of several markers of cross-cultural The quality of the information about suicide in India is
differences in the psychological valence of interpersonal quite limited, but the picture drawn from the eclectic
risk and protective factors for suicide, the suicide- mix of studies identified in this review indicate that
protective effect of being married reported in high- it is an important and growing public health problem
income countries does not appear to be confirmed in that is not being given sufficient attention by the
studies from India and China, where single individuals government or the society at large. Compared to the
are no more vulnerable to suicide than their married pattern of suicides in high-income countries, suicide in
counterparts.[53,60] India is more prevalent in women (particularly young
Psychological autopsy studies conducted in women), is much more likely to involve ingestion of
developed countries report that psychiatric disorders pesticides, and is more closely associated with poverty
are present in about 90% of people who die by suicide and less closely associated with mental illness. Initial
and that these conditions contribute 47 to 74% of the targets for suicide prevention in India should include:
population attributable risk of suicide.[61,62] In our review (a) decriminalization of suicide; (b) restricting access to
mental illness – particularly alcohol use disorders – pesticides; and (c) improving the monitoring of fatal and
were also important risk factors for suicide, but not to non-fatal suicidal behavior.
the extent reported in high-income counties. Almost
all studies from high-income countries indicate that Conflict of Interest
affective disorder (i.e., depression and mania) is the
mental disorder most closely associated with suicide The author reports no conflict of interest related to this
(followed by substance abuse and schizophrenia)[61,63] manuscript.
and that more than half of all people who die of suicide
meet current diagnostic criteria for an affective dis-
order.[64] This review suggests that depression plays a Funding
less dominant role in suicide in India. Other studies The authors did not receive any funding support to
find that in Asian cultures impulse control disorders are conduct this review.

有关印度自杀的系统综述
Anil RANE, Abhijit NADKARNI
背景：自杀是印度重要的死亡原因之一，但基于印度 男性，而 30 岁及以上的人群则正好相反。自缢和服用
国家犯罪统计局数据估算的自杀率并不可靠。 有机磷农药是最常见的自杀方式，自焚在女性较为常
目标：系统回顾现有的有关印度自杀及自杀相关因素 见。社会经济地位低、精神疾病（尤其是酒精滥用）
的文献。 和人际交往障碍是与自杀关系最为密切的因素。
方 法： 选 择 适 当 的 检 索 词 在 PubMed，PsycINFO， 结论： 有关印度自杀的数据质量非常有限。但显而易
EMBASE，全球健康，谷歌学术和 IndMED 数据库中查 见，自杀是一个重要且日益严重的公共卫生问题。相
找文献。查找到的论文摘要由两位作者分别独立筛选 对于高收入国家而言，印度自杀特点为：女性（尤其
是否符合纳入标准，再从筛选出的论文全文中摘录标 是年轻妇女）自杀率高于男性、较多选择服用农药的
准化数据。 自杀方式、与贫穷因素关系更为紧密而与精神疾病因
素相关性较低。
结果：本研究筛选出符合纳入标准的 36 篇论文进行分
析。由于抽样过程和研究方法的异质性，荟萃分析的
方法不可行。在印度部分农村地区的死因推断研究中 关键词：自杀，印度，系统综述，有机磷农药，精神
报道的自杀率较高，每 10 万人口中有 82 至 95 人自杀， 病
比官方报道的全国自杀率高出 8 倍。其中 20 至 29 岁
人群的自杀率最高；30 岁以下人群中女性自杀率高于 本文全文中文版从 2014 年 5 月 15 日起在 www.saponline.org 可供免费阅览下载

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Anil Rane obtained his Bachelor’s degree from Goa Medical College, India in 1999 and his MD
in Psychiatry from the Institute of Psychiatry & Human Behaviour in Bambolim in 2003. He has
worked as a lecturer in Psychiatry in the same department since 2006. He is also the secretary of
the Psychiatric Society of Goa. His main research interests are substance use disorders and the
occurrence of non-communicable diseases in persons with severe mental illness.

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