Suicide rarely impacts our consciousness, except when news involving a celebrity hits television screens or newspaper headlines. It is not something, though, that our society can afford to deny. It is not glamorous. It is an unnecessary end of a life, which has memories, beliefs, feelings, thoughts, relationships, experiences and aspirations.
The sense of isolation of the person who attempts suicide is unfathomable. Sometimes, suicide may seem like an impulsive decision to an overwhelming crisis; at other times it may seem that it is a response to ongoing anguish and despair, when the individual loses the reason to live.
More often than not it happens when the balance between pain and suffering and between the reasons to live and the resources to cope with the difficulties faced in life is tipped towards hopelessness.Alarming reality
Beyond the personal reality of individual lives, the Indian reality on suicide is alarming. In a recent study focussed on India and published in The Lancet , a premier medical journal, it was estimated that for nearly 1,87,000 people in 2010 the cause of death was suicide. It was estimated in the same study that in India the standardised rate of suicide per 1,00,000 people aged 15 years or older, of 26·3 for men and 17·5 for women, was the second highest in the world.
The same study also reported suicide as the second most common cause of death for unnatural death — that is, more deaths are caused by suicide than by HIV/AIDS, cancer or cardiac illness. This is in the context of the situation in India — where 90 per cent of people who need mental health support do not have access to it. There is a significant human resource gap of mental health professionals. There is no policy for mental health or suicide prevention. And attempted suicide is still a crime!
Suicide, however, is not merely a health issue. We are a society in transition. There is significant violence, discrimination, exclusion and intolerance that form the social canvas of our times. There is a mismatch of aspirations and opportunity. Relationships are not based on respect and knowledge, but transactional contracts of one-upmanship. The discourse with our children is full of criticism and unreasonable expectations. The young, the old, the women and men in our society are vulnerable to demoralisation. Such demoralisation is a breeding ground for helplessness.
Is it possible for a society to reach out to people who are thinking about suicide before they attempt it with a fatal or a non-fatal end? Is it possible for a person to be offered support? Is it possible to help a person step back and see at least a speck of hope to explore alternatives and choices one more time?
The answer is a clear ‘yes’.
Without waiting for changes in the law or development of a policy, we all must try and inform and skill ourselves to respond to people experiencing psychological distress.
We must start by creating space for conversations in our relationships. Let us learn not to judge people or force our opinions on them. Just listen and validate the person’s experiences. We must learn to recognise symptoms of psychological distress and illness. If people tell you that they are sad or feeling hopeless, do take them seriously. If they have lost interest, if they are not able to enjoy, if they have become withdrawn or if they are extremely anxious, recognise these as features of depression, which if treated early, will prevent suicidal thoughts.
Do not just ask a depressed person to “pull up their socks” and live. Explore if they have had thoughts of harming themselves. Have they attempted self-harm in the past? If they have, it increases the likelihood that they might attempt it again. Also remember, if the person is intoxicated, it is more likely that he/she would attempt suicide.
Do not patronise. Do not make the person feel guilty. Be with the person. Your words have power; do not use them in a trivial manner. Sometimes, sensitive silence is better than goading. Help people navigate their problems without imposing a solution on them.Vulnerable people
If you are overwhelmed, do not be brave by trying to support the person on your own. Involve other people, share the responsibility of caring. Most large cities have volunteer organisations that provide phone-based support to people in distress. Most medical colleges have departments of psychiatry and most district headquarters have psychiatrists in private practice. If you cannot find a mental health professional, approach any system that provides support to people who are vulnerable such as the resident welfare association, the police, a health service, etc.
There is a psychological framework that precipitates suicidal thoughts. It includes black-and-white thinking, a sense of hopelessness and helplessness. The person also may be coping with poverty, unemployment and debt. There may be a rejection in a relationship and failure in examinations. For women, experiences of violence and abuse in intimate relationships may be a determining factor.
For a large number of people, there may be an underlying illness like depression or schizophrenia. There may be a history of substance abuse with alcohol, cannabis or benzodiazepines.
There is a relatively easy access to means of suicide in our country. Pesticides and easily available “prescription only” medicines create a risky environment for such vulnerable individuals.
How does an individual who is considering suicide as an option help himself/herself? Let me address you directly and urge you to seek help immediately. First, it is important to remember that there are many people who did step back and live and were able to be hopeful one more time. People are resilient and people do survive. You are resilient and you can survive!
Step back for a moment. Talk to someone. It could be a friend, a colleague, a family member, a counsellor, a spiritual person, or any other person that you may have access to.
You have a right to live. Plan the next hour to be with someone or talk to someone, then with his or her help, plan the next 24 hours. Include the step of seeking professional help in the plan.
During this time, do not attempt to solve all your problems or even answer the question as to why you should live. Just let someone know how you feel and be with them. No decisions need to be taken. Each passing moment will give you a breather and then you will be able to look at your experiences and problems afresh.Policy challenges
The lawmakers and policymakers have to shed their denial of mental health issues and put mental health and well-being on the agenda. The proposed Mental Health Care Bill which was recently introduced in the Rajya Sabha at least does two positive things: it creates a parity between health and mental health and it proposes to decriminalise suicide. Let us hope it is considered in the last session of this Lok Sabha.
The mental health policy has to clearly state goals and targets for reducing the frequency of suicide in the country. The access to mental health services in the community has to be increased substantively, and this will not only require a financial outlay for developing service delivery systems that do not exist, but also a change of thinking on how we develop a new mental health workforce. An immediate solution would be to embed online skills-based training on mental health and suicide prevention into training programmes for all teachers, doctors, nurses, psychologists, social workers, nurses and human resource professionals.
We have helplines and call centres for so many issues in this country. Is it not time for a 24x7 national suicide prevention hotline with trained professionals? Another step that would help decrease the rural suicide rates would be to increase awareness about locking pesticides away and safe.
We are the only country which perhaps spends more on investigating suicide as a crime instead of preventing it. Let us change that, for each life is as precious as any other.
(Dr. Achal Bhagat is senior consultant psychiatrist and psychotherapist, Apollo Hospitals, and chairperson, Saarthak, a mental health non-governmental organisation.)