Married women account for the highest proportion of suicide deaths among women in India

Excerpts from the Lancet study “Gender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016

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SDR: Suicide Death Rate

India had 17.8% of the global population in 2016, but accounted for 36·6% of the global suicide deaths among women and 24.3% among men. The proportion of global suicide deaths in India has increased since 1990 for both sexes, but more for women than for men. Young adults are taking their own lives in alarmingly high numbers, constituting a public health crisis. Suicide ranks first as the cause of death in India in both the age groups of 15–29 years and 15–39 years, as compared with its second and third rank globally in these age groups, respectively. The increasing suicide death rate (SDR) observed among the elderly in recent years will pose additional challenges. There are large differences in suicide deaths by sex and the SDRs vary substantially between the states. The trends presented over time for the Indian states by sex and age groups can inform suicide prevention policies and monitoring of suicide burden at the state level.

The SDR for women in India was slightly higher in the 1990s than for men, converging in 2001 and then diverging from 2002 with a decrease in the rate for women whereas the rate in men continued to be stagnant. India’s men-to-women SDR ratio was lower than the global ratio in 2016. Suicide deaths vary by sex around the world, with SDR in most countries higher in men than in women.

Several theories of convergence and divergence of the men-to-women SDR ratio with modernisation have been tested globally based on the hypothesis that it affects men and women differently with conflicting results. A previous attempt at understanding this relation for India using administrative data for suicide deaths was inconclusive. It is also speculated that these gender differences in SDR might be relatively less pronounced if suicide attempts were considered because women make more suicide attempts than men, but men are more likely to die in their attempts than women.

The national level estimates mask the large variations seen in suicide deaths at the state level in India, as evident from the wide range of SDR, men-to-women ratio, and observed-to-expected ratio for the states. Overall, suicides accounted for a lower proportion of deaths in the relatively less developed low and lower-middle epidemiological transition level (ETL) state groups than in the higher-middle and high ETL state groups. For both sexes, the differences in SDR were quite pronounced when comparing the state- level data that show a geographical divide.

The southern states of Andhra Pradesh, Karnataka, Tamil Nadu, and Telangana, which are in the higher-middle and high ETL groups, consistently had a higher SDR for both men and women. The central and western states show mid-level rates, with the exception of Chhattisgarh that had a high SDR among men. SDRs in the north and north-western states were generally low.

A mixed pattern was seen for the eastern states, with West Bengal having higher rates than the other states. In the north-eastern states, Tripura had among the highest SDRs and the other states had a mix of high and low SDRs, with the men-to-women SDR ratios generally much higher than the average for India. The levels of urbanisation, proportion of literate population, and difference in literacy attainment between men and women have been suggested as reasons for the variations in suicide deaths at the state level in India.

The nearly three times higher SDR observed in women in India as compared with the rate expected globally for geographies at similar levels of Socio-Demographic Index highlights the particular need to better understand the determinants of suicides among women in India. Globally and in India, differences in socially acceptable methods of dealing with stress and conflict for women and men, availability of and the preference for different means of suicide, differences in alcohol consumption patterns, domestic violence, poverty, and differences in care-seeking rates for mental disorders between women and men have been cited for gender differentials in SDR.

Married women account for the highest proportion of suicide deaths among women in India. Marriage is known to be less protective against suicide for women because of arranged and early marriage, young motherhood, low social status, domestic violence, and economic dependence. The trends in SDR in women in this study suggest the need to further assess the complex relationships between gender and suicidal behaviour to facilitate women-specific suicide prevention strategies. The Protection of Women from Domestic Violence Act has been in place in India since 2005, and it would be prudent to understand the effect it has had on suicide prevention among married women.

Perhaps, there are lessons to be learnt from China, which had one of the highest female SDRs in 1990 but reduced it by 70% in 2016. Nonetheless, SDR among men in India did not change much from 1990 to 2016, and remains higher than the global average, although not as striking as SDR in women. One of the reasons for this stagnation among men could be that only suicides of farmers have received attention from policy makers and the media in India, which could have resulted in neglect in dealing with suicide prevention in men overall. The persistent high suicide rate among men in India needs to be addressed.

A bimodal pattern for suicide deaths was seen for women, with a peak in suicide rates in younger women and then an increase after 70 years of age, which did not vary by ETL group. A somewhat similar pattern emerged for men as well, although the peak in the younger ages was much less distinct compared with that in women. Distinct age-related patterns in suicide death risk at the country level corresponding to different stages of economic development have been reported, with a bimodal pattern—as seen in India—seen in countries at an intermediate stage of industrialisation. One pronounced finding is that despite a reduction in SDR between 1990 and 2016 in younger women, the SDR among them continues to remain high.

Recently, high suicide deaths in adolescent girls have gained attention, with suicides having surpassed maternal mortality as the leading cause of death globally. Several forms of gender role differentiation and gender-based dis- crimination have been highlighted, including early marriage and a higher risk of depression, as possible reasons for this high SDR. India accounted for one-third of the global child marriages in 2014.

India launched its National Programme for Adolescent Health in 2014 that aimed to address mental, sexual, and reproductive health among other health needs. The programme has various indicators to track age at marriage and teenage pregnancies, depression, and gender-based violence, but does not explicitly mention suicidal ideation as an indicator, tracking of which is imperative given the study findings. Furthermore, there is a need to better understand the linkages between mental health and sexual and reproductive health, and rights for adolescent girls in India that constrain their aspirations and opportunities leading to higher suicide deaths.

For suicide among men in India, it appears that young adults are a vulnerable group, and marriage does not seem to be protective for them either. For the elderly, social isolation, depression, functional disability, and the feeling of being a burden on their family have been cited as reasons for suicidal ideation. However, not much is known about suicide in the elderly in India. With their increasing proportion in the population over time, the reasons for suicidal ideation and mental health issues in the elderly need to be explored urgently within the National Programme for Health Care of the Elderly in India to address the increasing suicide deaths in this age group.

Personal or social factors such as socioeconomic circumstances, interpersonal, social and cultural conflicts, alcoholism, financial problems, unemployment, and poor health are known as major reasons for suicide in India for both men and women. The use of poison, medication or drug overdose, and hanging has been reported as the most used means of suicide. The reasons for and the means used for suicide highlight the need to address the underlying social determinants of health through macroeconomic policies to protect the vulnerable in order to reduce suicide rates at the population level, to limit or reduce harmful use of pesticides or medicine by relevant regulatory frame- works, and to promote access to and availability of mental health services.

Until 2017, suicide was a criminal offence in India, which led to under-reporting of suicide deaths in the National Crime Records Bureau of India. Its decriminalisation is expected to have a major role in access to mental health treatment and possible reduction in under-reporting and stigma associated with suicide. Furthermore, appropriate reporting of suicides in the media could also contribute to possible reduction in stigma. The National Mental Health Policy of India launched in 2014, which explicitly aims to reduce suicide deaths and suicide attempts using various strategies; however, the implementation of this mental health programme has left much to be desired.

Very little has been done thus far for suicide prevention in India, and the projections for the SDG 2030 target are dismal, with the majority of the states with more than 80% of India’s population having less than 10% probability of reaching the SDG target. A comprehensive national suicide prevention strategy that systematically addresses the gender-specific multi-sectoral nature of suicide along with mental health is urgently needed to accelerate the probability of closing the gap towards the SDG target.

The disproportionately high suicide deaths in India are a public health crisis. Suicide ranks as the leading cause of death among young adults in India, and suicides among women need particular attention. This report provides a comprehensive assessment of the trends of suicide deaths in every state of India over the past quarter century. A national suicide prevention strategy is needed as a guide, which then has to be adapted at the state level to take into account the wide variations in trends between the states and the context of each state to reduce the burden of suicide deaths in India.

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