India State-Level Disease Burden Initiative Suicide Collaborators. Gender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990-2016

Literacy and Attitude Toward Suicide Among Doctors and Nurses: A Cross-Sectional Comparative Study

Introduction Globally, suicide remains a major public health problem and is the second most common cause of death in the 15-45 years age group. Awareness about suicide and the attitude of healthcare professionals regarding suicide are crucial factors determining the care for suicidal behaviors. The present study aimed to compare suicide literacy and attitude toward suicide between doctors and nurses and to explore the association between suicide literacy and attitude toward suicide. Methods A cross-sectional comparison study was conducted between doctors and nurses in a tertiary healthcare center in southern India. The demographic characteristics and work and suicide care experience were recorded using a semi-structured proforma. Literacy of Suicide Scale - Short Form (LOSS-SF) and Attitude Toward Suicide Questionnaire (ATTS) were used to assess the awareness about suicidal behaviors and attitudes toward suicide, respectively. Appropriate statistical tests were used to compare the outcome measures between doctors and nurses with the statistical significance set at p ≤ 0.05. Results A total of 600 healthcare professionals (doctors (n=300) and nurses (n=300)) were included. The doctors were older, had longer work experience, and demonstrated better suicide literacy, yet harbored more negative attitudes toward suicide than nurses. Among doctors, increasing levels of suicide literacy were negatively correlated with positive attitudes toward suicide. Among nurses, increasing age was negatively correlated with healthy attitudes toward suicide. Conclusion Doctors had better awareness of suicidal behaviors yet displayed negative attitudes toward people with suicidal behaviors. Despite having less suicide awareness, nurses exhibited positive attitudes toward suicide. Suicide literacy and attitudes toward suicide can have complex relationships mediated by multiple factors.

A Glossary of Distress Expressions Among Kannada-Speaking Urban Hindu Women

People's lived experiences of distress are complex, personal, and vary widely across cultures. So, too, do the terms and expressions people use to describe distress. This variation presents an engaging challenge for those doing intercultural work in transcultural psychiatry, global mental health, and psychological anthropology. This article details the findings of a study of common distress terminology among 63 Kannada-speaking Hindu women living in Mysuru, the second largest city in the state of Karnataka, South India. Very little existing scholarship focuses on cultural adaptation for speakers of Dravidian languages like Kannada; this study aims to fill this gap and support greater representation of this linguistic family in research on mental health, idioms of distress, and distress terminology. Between 2018 and 2019, we conducted a 3-phase study consisting of interviews, data reduction, and focus group discussions. The goal was to produce a non-exhaustive list of common Kannada distress terms that could be used in future research and practice to translate and culturally adapt mental health symptom scales or other global mental health tools.

Explaining Suicide Among Indian Women: Applying the Cultural Theory of Suicide to Indian Survivors of Gender-Based Violence Reporting Suicidal Ideation

Indian women account for 36.6% of suicide-related deaths worldwide and gender-based violence (GBV) is a key social determinant. The cultural theory of suicide (CTS), which synthesizes risk factors and explanations of suicide among racial/ethnic minorities, posits four tenets: idioms of distress, cultural sanctions, and social discord. Our study applied the CTS to Indian women from slums reporting GBV to explore (1) culturally relevant risk pathways towards suicidal ideation using qualitative analyses, and test (2) the association between idioms of distress and suicidal ideation. 112 women from urban slums were recruited and 99 completed surveys. A subset were administered qualitative interviews. Aim 1 explored the CTS framework among participants describing suicidal ideation in qualitative interviews [n = 18]; Aim 2 explored if idioms of distress severity was associated with suicidal ideation through an ANCOVA [N = 99]. Idioms of distress such as 'tension' indicated suicidal ideation. Communities did not sanction suicidal ideation, leading to secrecy regarding disclosure. Women in 'love marriages' (versus arranged marriages) reported minority stress. Social discord heightened suicidal thoughts. Results of the ANCOVA confirmed that women reporting suicidal ideation had higher idioms of distress severity (M = 28.56, SD = 6.37), compared to women who did not (M = 21.77, SD = 6.07), F(1, 96) = 28.58, p < .001 (ηp2 = .23). Our study empirically validates the CTS among Indian GBV survivors. Culturally responsive suicide prevention can include assessing idioms of distress, improving family support, and educating to reduce stigma and enhance help-seeking.

"Dressed like boys, hair trimmed, a nalla kutti otherwise": construction of queer suicide in Indian online news media

Suicide is a significant newsworthy event, and the media often cover cases involving queer individuals. However, there is a notable lack of research on the quality of reporting of queer suicide cases within the Indian context. This article aims to address the existing gap in Indian online news media by investigating the portrayal of queer suicide via content analysis. Content analysis involves qualitatively condensing and interpreting data to extract key consistencies and meanings from a plethora of qualitative material. The newspapers considered span from 2005 to 2022, with data collection conducted in 2023. The author alone identified news articles on queer suicide and conducted the subsequent content analysis. The study reveals that reporting on queer suicide tends to divide queer couples into the gender binary and describes what it deems to be careless sexual conduct driven by obsessive queer love, which, in turn, is blamed for the suicide. Moreover, these reports often do the following: feature families who refuse to accept their children's identities, adopt dread-filled tones, and cite experts who provide incorrect information while engaging in victim blaming. As a result, the quality of queer suicide reporting in Indian newspapers is deemed substandard and offensive. To address this issue, the study proposes the need for training and curriculum updates in journalistic courses. This way, reporters can develop the skills necessary to sensitively and respectfully report on queer individuals in general and on queer suicide in particular.

Machine Learning-Based Prediction of Suicidal Thinking in Adolescents by Derivation and Validation in 3 Independent Worldwide Cohorts: Algorithm Development and Validation Study

BACKGROUND

Suicide is the second-leading cause of death among adolescents and is associated with clusters of suicides. Despite numerous studies on this preventable cause of death, the focus has primarily been on single nations and traditional statistical methods.

OBJECTIVE

This study aims to develop a predictive model for adolescent suicidal thinking using multinational data sets and machine learning (ML).

METHODS

We used data from the Korea Youth Risk Behavior Web-based Survey with 566,875 adolescents aged between 13 and 18 years and conducted external validation using the Youth Risk Behavior Survey with 103,874 adolescents and Norway's University National General Survey with 19,574 adolescents. Several tree-based ML models were developed, and feature importance and Shapley additive explanations values were analyzed to identify risk factors for adolescent suicidal thinking.

RESULTS

When trained on the Korea Youth Risk Behavior Web-based Survey data from South Korea with a 95% CI, the XGBoost model reported an area under the receiver operating characteristic (AUROC) curve of 90.06% (95% CI 89.97-90.16), displaying superior performance compared to other models. For external validation using the Youth Risk Behavior Survey data from the United States and the University National General Survey from Norway, the XGBoost model achieved AUROCs of 83.09% and 81.27%, respectively. Across all data sets, XGBoost consistently outperformed the other models with the highest AUROC score, and was selected as the optimal model. In terms of predictors of suicidal thinking, feelings of sadness and despair were the most influential, accounting for 57.4% of the impact, followed by stress status at 19.8%. This was followed by age (5.7%), household income (4%), academic achievement (3.4%), sex (2.1%), and others, which contributed less than 2% each.

CONCLUSIONS

This study used ML by integrating diverse data sets from 3 countries to address adolescent suicide. The findings highlight the important role of emotional health indicators in predicting suicidal thinking among adolescents. Specifically, sadness and despair were identified as the most significant predictors, followed by stressful conditions and age. These findings emphasize the critical need for early diagnosis and prevention of mental health issues during adolescence.

Unpacking the 'black box' of suicide: A latent class analysis predicting profiles of suicidal ideation in a longitudinal cohort of adolescent girls from India

INTRODUCTION

Indian women account for 37% of global suicide-related deaths. As suicide is a growing concern among adolescent girls, identifying the social determinants of suicide with this group targeted prevention. We selected social determinants that include intersectional identities and broader syndemics; we then used longitudinal data from a prospective cohort of adolescent girls from Northern India to classify them into unique profiles across multiple socioecological levels.

METHODS

Girls aged 10-19 (N = 11,864) completed self-report questionnaires measuring socio-demographic and trauma exposure variables. At three-year follow-up, they were asked to indicate current suicidal ideation (SI). We conducted latent class analysis (LCA) to classify profiles and then predicted risk of current SI at three-year follow-up.

RESULTS

LCA supported a four-class solution: a 'privileged' class (Class 1; n = 1,470), a 'modal' class (Class 2; n = 7,449), an 'intergenerational violence' class (Class 3; n = 2,113), and a 'psychological distress' class (Class 4; n = 732). Classes significantly predicted odds ratios (OR) for SI at follow up; women in Class 4 were associated with the greatest likelihood of SI (OR 1.84, 95% CI 1.38, 2.47), suggesting that psychological distress factors confer greatest risk.

CONCLUSION

Results of the distinct classes of risk and protective factors indicate targets for policy-level interventions. Disrupting cycles of psychological distress and substance use, increasing access to behavioral interventions, and intervening to mitigate intergenerational violence may be particularly impactful with this population.

Similar and different? A cross-cultural comparison of the prevalence, course of and factors associated with suicidal thoughts and behaviors in first-episode psychosis in Chennai, India and Montreal, Canada

BACKGROUND

Data from high-income countries (HICs) show a high risk of suicidal thoughts and behaviors (STBs) in first-episode psychosis (FEP). It is unknown, however, whether rates and associated factors differ in low- and middle-income countries (LMICs).

AIMS

We therefore aimed to compare the 2-year course of STBs and associated factors in persons with FEP treated in two similarly structured early intervention services in Chennai, India and Montreal, Canada.

METHOD

To ensure fit to the data that included persons without STBs and with varying STBs' severity, a hurdle model was conducted by site, including known predictors of STBs. The 2-year evolution of STBs was compared by site with mixed-effects ordered logistic regression.

RESULTS

The study included 333 FEP patients (168 in Chennai, 165 in Montreal). A significant decrease in STBs was observed at both sites (OR = 0.87; 95% CI [0.84, 0.90]), with the greatest decline in the first 2 months of follow-up. Although three Chennai women died by suicide in the first 4 months (none in Montreal), Chennai patients had a lower risk of STBs over follow-up (OR = 0.44; 95% CI [0.23, 0.81]). Some factors (depression, history of suicide attempts) were consistently associated with STBs across contexts, while others (gender, history of suicidal ideation, relationship status) were associated at only one of the two sites.

CONCLUSIONS

This is the first study to compare STBs in FEP between two distinct geo-sociocultural contexts (an HIC and an LMIC). At both sites, STBs reduced after treatment initiation, suggesting that early intervention reduces STBs across contexts. At both sites, for some patients, STBs persisted or first appeared during follow-up, indicating need for suicide prevention throughout follow-up. Our study demonstrates contextual variations in rates and factors associated with STBs. This has implications for tailoring suicide prevention and makes the case for more research on STBs in FEP in diverse contexts.

Suicidal Behavior and Its Association With Psychological Distress, Coping Mechanisms, and Resilience: A Cross-Sectional Study

Introduction Recent literature reveals that psychological factors such as resilience and coping mechanisms can act as buffers against suicide risk. Indian literature on the interplay between psychological risk and protective factors of suicidal behavior is scarce. Methods A cross-sectional descriptive study was done among suicide attempters in a tertiary care hospital in Southern India. A semi-structured proforma was used to obtain sociodemographic data and suicide attempt characteristics. Suicide intent, lethality, stressful life events, perceived stress, subjective distress, coping strategies, and resilience were recorded using standard rating scales. Inferential analyses were carried out with p≤ 0.05 set as statistical significance. Results Pesticide poisoning (46.7%) was the most common mode of suicide attempt. Significant gender differences emerged in the mode of suicide attempt, coping strategies, and resilience. Depression (48.7%) was the most common psychiatric comorbidity. Increased perceived stress was associated with the presence of psychiatric comorbidity, past history of suicide attempts, and high-intent suicide attempts. Maladaptive coping strategies were associated with substance abuse and a history of past suicide attempts. Low resilience levels were associated with hanging attempts, psychiatric or substance use disorder comorbidity, past history of suicide attempts, high-intent suicide attempts, and less lethal suicide attempts. Conclusion Perceived stress levels, coping strategies, and resilience have significant relationships with suicidal behavior and act as avenues for suicide prevention efforts.

Review of the India Adolescent Health Strategy in the context of disease burden among adolescents

Background

A nuanced understanding of the health needs of adolescents in the context of the India Adolescent Health Strategy (IAHS) is needed to inform policy interventions for improving the health and well-being of adolescents in India.

Methods

Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, we identified the top ten causes of years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) disaggregated by sex and age group (10-14 and 15-19 years) for India and its states in 2019. To inform the IAHS of refinement or expansion in focus needed to improve adolescent health in India, we reviewed the extent to which the top 10 causes of disease burden are addressed in the IAHS, and the availability of and age- and sex-disaggregation in the service utilisation data for adolescents captured in the Adolescent Friendly Health Clinic monitoring information system (AFHC MIS) and Health Management Information System (HMIS). We also reviewed the availability of and age-and sex-disaggregation in the data capture at the population level for the IAHS outcome indicators in the data sources identified in the IAHS operational framework.

Findings

Females in the 10-14 and 15-19 years age groups suffered 6.75 million and 9.25 million DALYs, respectively, 39.1% and 44.2% of which were YLLs; the corresponding DALYs for males were 6.71 million and 9.65 million (42.3% and 41.1% YLLs), respectively. Within the 6 thematic areas of the IAHS, most strategies and indicators identified are for sexual and reproductive health followed by nutrition, and broadly these conditions accounted for YLDs and not YLLs in adolescents. Significant gaps in the IAHS in comparison to the disease burden for fatal diseases and conditions were seen across injuries, communicable diseases, and non-communicable diseases. Injuries accounted for 65.9% and 45.3% of YLLs in males and females aged 15-19 years, and 40.8% in males aged 10-14 years. Specifically, road injuries (15.3%, 95% UI 11.0-18.0) and self-harm (11.3%, 95% UI 8.7-14.2) accounted for most of the injury deaths in 15-19 years whereas drowning (7.7% 95% UI 5.8-9.6) and road injuries (6.9%, 95% UI 4.7-8.6) accounted for the most injury deaths in 10-14 years males. However, only self-harm and gender-based violence are specifically addressed in the IAHS with non-specific interventions for other injuries. Diarrhoea, lower respiratory infections, malaria, encephalitis, tuberculosis, typhoid, cirrhosis, and hepatitis are the other disease conditions accounting for YLLs and DALYs in adolescents but these are neither addressed in the IAHS nor in service provision under the AFHC MIS. There is no age- or sex-disaggregation in the cause of death data captured in the HMIS to allow an understanding of mortality in adolescents. For the IAHS outcome indicators at the population level, data capture for the 10-14 years irrespective of sex was largely missing from the population surveys and none of the surveys captured data for either females or males aged 15-19 years for physical inactivity and mental health indicators.

Interpretation

The considerable differences seen in the IAHS thematic focus as compared with the leading causes of fatal and non-fatal disease burden in adolescents in India, and in the availability of population-level data to monitor the outcome indicators of the IAHS can pose substantial limitations for improving adolescent health in India. The findings in this paper can be utilized by decision makers to refine action aimed at improving adolescent health and well-being.

Funding

Bill & Melinda Gates Foundation.

National policies and programs for perinatal mental health in India: A systematic review

BACKGROUND

India is the most populous country in the world with millions of births annually. Perinatal mental disorders (PMDs) are prevalent worldwide including in India. This study was undertaken to evaluate how mental health is addressed in national maternity and mental health policies and programs in India.

METHODS

We conducted a systematic review of the national policies and programs in India related to maternity care and mental health. The identified policies and programs were analysed using health policy triangle framework.

RESULTS

Our search yielded 11 relevant documents and no peer reviewed publications. No specific national policy or program on maternal mental health could be identified. Universal access to health and mental health including for women and children was clearly articulated in both national mental health and maternity policies, which emphasised that access to mental health care and treatment is a fundamental right. There were few details about how the programs and policies were developed and no accounts of consultations with community members or service providers in their formation.

CONCLUSION

National maternity and mental health policies and programs in India appear not to consider perinatal mental health. There are promising state-based initiatives, but, given the disease burden of PMDs in India, the absence of a national policy leads to unrecognized and unmet needs of women in the states without these measures. These inequalities can be effectively minimized by well implemented national policies for perinatal mental health, accompanied by evidence-based locally tailored programs and interventions across the country.

Prevalence, correlates and common methods of non-suicidal self-injury in South Asia: a systematic review

INTRODUCTION

The dynamics of self-harm vary substantially around the world, yet it is severely under-researched outside of a small number of high-income 'Western' countries. South Asia is disproportionately impacted by suicide, yet we know less about non-suicidal self-injury (NSSI) in the region.

OBJECTIVE

To review and summarise evidence on the prevalence, correlates and common methods of NSSI in South Asia.

METHODS

We searched Medline, Embase and PsycINFO for the period 1 January 2000 to 31 August 2023, for peer-reviewed observational studies. A total of 11 studies from eight South Asian countries that reported prevalence and/or correlates of NSSI were included in this review. We assessed the quality of the studies using the Study Quality Assessment Tools for Observational Cohort and Cross-Sectional Studies. We used meta-regression to describe the sources of heterogeneity. Abstracted data were summarised using thematic synthesis.

RESULTS

For non-clinical populations, the 12-month prevalence of NSSI ranged from 3.2% to 44.8%, and the lifetime prevalence ranged from 21% to 33%. For clinical populations, the 12-month prevalence of NSSI ranged from 5% to 16.4%, while the lifetime prevalence ranged from 2% to 27%. Male sex, unemployment, financial stress, history of suicidal behaviour and depression were associated with a higher risk of NSSI. Better access to counselling services, higher self-esteem and self-knowledge were associated with a lower risk of NSSI.

CONCLUSION

The burden of NSSI in South Asia appears to be high in both clinical and non-clinical populations. Further research, especially with general population samples, is needed to build evidence on the epidemiology, context and meaning of NSSI in South Asia to inform the design of context-specific interventions.

PROSPERO REGISTRATION NUMBER

CRD42022342536.

Banning highly hazardous pesticides saves the lives of young people, particularly females, in low- and middle-income countries

Pesticide self-poisoning is a public health problem mostly affecting low- and middle-income countries. In Sri Lanka, India and China suicide rates have reduced among young people, particularly females, following highly hazardous pesticides (HHP) bans. This success story requires attention to encourage more research on differential effects of HHP bans.

Changing profile of suicide methods in India: 2014-2021

BACKGROUND

Restricting access to suicide methods is one of the most effective suicide prevention approaches.

METHODS

Trends in method specific suicide rates (2014-2021) in India were calculated using National Crime Records Bureau data (NCRB) by sex and geographical region. Joinpoint regression analysis was used to empirically identify any changes in suicide trends.

RESULTS

Suicide rates by hanging increased from 6.08 to 10.0 per 100,000 population among males and from 2.55 to 3.56 per 100,000 among females over the study period. Insecticide poisoning suicide rates also increased from 1.51 to 2.73 per 100,000 among males and from 0.74 to 1.14 per 100,000 among females. Suicide by self-immolation decreased over the study period among both sexes. In general, these national trends were mirrored among different regions. Joinpoint regression indicated an increase in suicide by hanging (annual percentage change (APC) of 12.3 among males between 2018 and 2021 and 4.9 among females between 2014 and 2021) and an increase in male suicide by insecticide poisoning between 2014 and 2021 (APC of 4.2) while a decrease in self-immolation rates was noted among males (APC of -12.7 between 2014 and 2021) and females (APC of -16.5 between 2016 and 2021).

LIMITATION

The NCRB data might underestimate true suicide rates.

CONCLUSION

Hanging suicides and insecticides poisoning suicides observed an increasing trend between 2014 and 2021. Self-immolation rates decreased during the study period which might be, in part, associated with the initiative to provide clean cooking fuel to households. Ban on lethal pesticides must be prioritised which might help lower insecticide poisoning suicide rates.

Prevalence of suicidal ideation and suicide attempts in individuals with psychosis and bipolar disorder in South Asia: systematic review and meta-analysis

BACKGROUND

Suicidal ideation and attempts are growing public health concerns globally. Evidence from high-income countries suggests that individuals with psychosis and bipolar disorder are at increased risk of suicidal ideation and attempts, but there is a scarcity of evidence from South Asia.

AIMS

To estimate the prevalence of suicidal ideation and attempts in individuals with psychosis and bipolar disorder in South Asia.

METHOD

In this systematic review and meta-analysis, four databases (PsycINFO, Web of Science, EMBASE and Medline) were searched until December 2022. Pooled prevalence was estimated with random-effects models. Heterogeneity was quantified with the I2-statistic.

RESULTS

The pooled sample size across the 21 studies was 3745 participants, 1941 (51.8%) of which were male. The pooled prevalence of suicide attempts in South Asian people with either psychosis or bipolar disorder was 22% (95% CI 17-27; n = 15). The pooled prevalence of suicidal ideation with psychosis or bipolar disorder combined was 38% (95% CI 27-51; n = 10). Meta-regression, subgroup and sensitivity analysis showed that the pooled prevalence estimates for both suicide attempt and ideation remained unaffected by variations in critical appraisal ratings and study designs. Only one study reported data on suicide-related deaths.

CONCLUSIONS

One in four individuals diagnosed with psychosis or bipolar disorder have reported suicide attempts, whereas up to one in three have experienced suicidal ideation. These findings underscore the urgent need for clinicians to regularly assess and monitor suicidal ideation and attempts among individuals with these disorders in South Asia.

Development of an IEC resource (brochure) on suicide prevention for college students: A qualitative study in the Indian context

BACKGROUND

Information Education Communication (IEC) materials play a vital role in behavior change by raising awareness about health issues. In India, suicide is the leading cause of death in the age group of 15-39 years, exemplifying the pressing need for raising awareness about suicide prevention. This study aimed to develop a brochure on suicide prevention for young adults with the help of scientific methodology.

MATERIALS AND METHODS

A cross-sectional qualitative research design was used in the study, and purposive sampling was used to collect the data. The study analyzed the awareness level and existing knowledge gap about suicide prevention among college students with the help of focus group discussions (FGDs) conducted independently among mental health experts, college teachers, and college students. Based on the findings from the FGDs, a comprehensive brochure was developed. The qualitative data collected by FGDs were analyzed using direct content analysis.

RESULTS

The findings of the FGDs helped identify the knowledge gaps with regard to young adult suicide prevention, and a brochure was prepared to address the same.

CONCLUSION

The development of young adult suicide prevention IEC resources pertinent to Indian settings is crucial. To bridge the knowledge gap on suicide prevention among college students and raise awareness, a brochure was developed based on scientific findings of the FGDs.

Progress towards universal health coverage in the context of mental disorders in India: evidence from national sample survey data

BACKGROUND

Universal health coverage (UHC) has emerged as one of the important health policy discourses under the current sustainable development goals in the world. UHC in individual disease conditions is a must for attaining overall UHC. This study measures progress towards UHC in terms of access to health care and financial protection among individuals with mental disorders in India.

METHODS

Data from the 75th Round National Sample Survey (NSS), 2017-18, was used, which is the latest round on health in India. Data collected from 555,115 individuals (rural: 325,232; urban: 229,232), from randomly selected 8077 villages and 6181 urban areas, included 283 outpatient and 374 hospitalization cases due to mental disorders in India. Logistic regression models were used for analyses.

RESULTS

Self-reporting of mental disorders was considerably lower than the actual disease burden in India. However, self-reporting of ailment was 1.73 times higher (95% CI: 1.18-2.52, p < 0.05) among the richest income group population compared to the poorest in India. The private sector was a major service provider of mental health services with a larger share for outpatient (66.1%) than inpatient care (59.2%). Over 63% of individuals with a mental disorder who reported private sector hospitalization noted unavailability or poor service quality at public facilities. Only 23% of individuals hospitalized had health insurance coverage at All India level. However, health insurance coverage among poorest economic class was a meagre 3.4%. Average out-of-pocket expenditure during hospitalization (public: 123 USD; private: 576 USD) and outpatient care (public: 8 USD; private: 37 USD) was significantly higher in the private sector than in the public sector. Chances of facing catastrophic health expenditure at 10% threshold were 23.33 times (95% CI: 10.85-50.17; p < 0.001) higher under private sector than public sector during hospitalization. Expenditure on medicine, as the share of total medical expenditure, was highest for hospitalization (public: 45%, private:39.5%) and outpatient care (public: 74.1%, private:39.7%).

CONCLUSIONS

Social determinants play a vital role in access to healthcare and financial protection among individuals with mental disorders in India. For achieving UHC in mental disorders, India needs to address the gaps in access and financial protection for individuals with mental disorders.

TRIAL REGISTRATION

Not applicable.

A qualitative study on perspectives of undergraduate professional students on suicide and recommendations for an effective suicide prevention program

Background

Suicide has become a leading cause of death among 15- to 39-year-olds. Recent data suggests that one student commits suicide every 60 seconds in India. One of the suicide preventive strategies adopted is the introduction of a crisis helpline for students but the effectiveness of this support in preventing suicide remains questionable. Our study aims to find out the perspectives of students on suicide and their recommendations for an effective suicide prevention program.

Method

A qualitative design with focus group discussions was used to collect data. A universal sampling technique was adopted and the data were analyzed using the framework method.

Results

A total of 830 students were divided into 70 groups with each group having 12 to 15 students participating in the focus group discussion. Several themes and subthemes emerged from the discussion. Overall, students had a poor understanding of people who attempt suicide, elaborated the factors instigating a person to make a suicidal attempt, barriers to access help and their views on effective crisis intervention service.

Conclusion

The study identified student perspectives on suicide and the challenges perceived by the students for the effective implementation of a crisis intervention program for suicide prevention.

Suicide in Married Women: An Autopsy Study

To consider death by suicide, as a method to escape their problems, is accepting defeat. Before embarking on the journey of marriage, one envisions the best of life and has a lot of hope for their future life. However, demands of dowry and domestic abuse by the husband can cut such visions short. Suicidal deaths among women especially married women have been increasing in Indian society. Various cultural, religious, and social values have a major role to play. In our study, we analyzed suicidal deaths in married women and tried to find the socio-demographic findings that have led these women to commit suicide. The autopsies were conducted from January 2014 to July 2015 at Kempegowda Institute of Medical Sciences, Bangalore. The highest incidence of suicide was found in the age group of 26-32 years, who were homemakers and within seven years of marriage. In a maximum of cases, abuse for dowry or other reasons was quoted as the reason to commit suicide. We also found that most of the decedents choose to hang themselves to commit suicide followed by the consumption of poison.

Examining the relationship between risky sexual behavior and suicidal thoughts among unmarried adolescents in India

Addressing the problem of suicidal thoughts in adolescents requires understanding the associated risk factors. Multiple studies have shown that risky sexual behavior affected the adolescents' psychological health that leads to their suicidal thoughts, behaviors and attempts. This study aimed to identify the association between various risky sexual behaviours and suicidal thoughts among unmarried adolescents in India. We used data collected from 4221 unmarried adolescent boys and 5987 unmarried adolescent girls aged 10-19 years, from the two rounds of the Understanding the Lives of Adolescents and Young Adults (UDAYA) survey. Descriptive analysis was done to observe changes in the selected variables from wave-1 to wave-2. Random effect regression analysis was used to estimate the association of suicidal thoughts among unmarried adolescents with their risky sexual behaviours. The percentage of adolescent boys having suicidal thoughts increased from 1.35% in wave 1 to 2.19% in wave 2. Among adolescent girls, the percentage increased from 2.92% in wave 1 to 5.05% in wave 2. A proportion of 3.26% adolescent boys had more than one sexual partner during wave 1 whereas in wave 2, it rose to 8.71%, while in case of adolescent girls, the estimates only increased from 0.26% at wave 1 to 0.78% at wave 2. Nearly 4.55% boys and 1.37% girls had early sexual debut. Almost five percentage boys were sexually active at wave 1 whereas in wave 2, it rose to 13.56%, while among adolescent girls, the estimates decreased from 1.54% at wave 1 to 1.51% at wave 2. Contraceptive use increased over time among both adolescent boy and girls. Also, a large proportion of adolescent boys reported watching pornography (27.08% at waive 1 and 49.39% at wave 2) compared to adolescent girls (4.46% at wave 1 and 13.10% at wave 2). Adolescents who had more than one sexual partner [Coef: 0.04; p < 0.001], exposed to early sexual debut [Coef; 0.019; p < 0.01], sexually active [Coef: 0.058; p < 0.001] and reported watching pornography [Coef: 0.017; p < 0.001] were more likely to have suicidal thoughts. Adolescent boys and girls with risky sexual behaviors are likely to be at a higher risk of suicidal ideation, and thus, they should be treated with special care and attention by local healthcare practitioners.

Sociodemographic characteristics of women who died by suicide in India from 2014 to 2020: findings from surveillance data

BACKGROUND

Women in India have twice the suicide death rate (SDR) compared with the global average for women. The aim of this study is to present a systematic understanding of sociodemographic risk factors, reasons for suicide deaths, and methods of suicide among women in India at the state level over time.

METHODS

Administrative data on suicide deaths among women by education level, marital status, and occupation, and reason for and method of suicide were extracted from the National Crimes Record Bureau reports for years 2014 to 2020. We extrapolated SDR at the population level for Indian women by education, marital status, and occupation to understand the sociodemography of these suicide deaths for India and its states. We reported the reasons for and methods of suicide deaths among Indian women at the state level over this period.

FINDINGS

SDR was higher among women with education of class 6 or more (10·2; 95% CI 10·1-10·4) than those with no education (3·8; 3·7-3·9) or education until class 5 (5·4; 5·2-5·5) in India in 2020, with similar patterns in most states. SDR declined between 2014 and 2020 for women with education until class 5. Women currently married accounted for 28 085 (63·1%) of 44 498 suicide deaths in India, 8336 (56·2%) of 14 840 in less developed states, and 19 661 (66·9%) of 29 407 in more developed states in 2020. For India, women currently married had a significantly higher SDR (8·1; 8·0-8·2) than those never married in 2014. However, women who never married had a significantly higher SDR (8·4; 8·2-8·5) in 2020 than those who were currently married. Many individual states in 2020 had similar SDR for women who never married and those who are currently married. Housewife as an occupation accounted for 50% or more of suicide deaths from 2014 to 2020 in India and its states. Family problems was the most common reason for suicide from 2014 to 2020, accounting for 16 140 (36·3%) of 44 498 suicide deaths in India, 5268 (35·5%) of 14 840 in less developed states, and 10 803 (36·7%) of 29 407 in more developed states in 2020. Hanging was the leading mean of suicide from 2014 to 2020. Insecticide or poison consumption was the second leading cause of suicide, accounting for 2228 (15·0%) of all 14 840 suicide deaths in less developed states and 5753 (19·6%) of 29 407 in more developed states, with a near 70·0% increase in the use of this method from 2014 to 2020.

INTERPRETATION

The higher SDR among women who have received an education, similar SDR between women currently married and never married, and variations in the reasons for and means of suicide at the state level highlight the need to incorporate sociological insights into how the external social environment can matter for women to better understand the complexity of suicide and determine how to effectively intervene.

FUNDING

Bill & Melinda Gates Foundation.

Potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people: A conceptual framework and lines of enquiry for research and policy

Mental health is inextricably linked to both poverty and future life chances such as education, skills, labour market attachment and social function. Poverty can lead to poorer mental health, which reduces opportunities and increases the risk of lifetime poverty. Cash transfer programmes are one of the most common strategies to reduce poverty and now reach substantial proportions of populations living in low- and middle-income countries. Because of their rapid expansion in response to the COVID-19 pandemic, they have recently gained even more importance. Recently, there have been suggestions that these cash transfers might improve youth mental health, disrupting the cycle of disadvantage at a critical period of life. Here, we present a conceptual framework describing potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people. Furthermore, we explore how theories from behavioural economics and cognitive psychology could be used to more specifically target these mechanisms and optimise the impact of cash transfers on youth mental health and life chances. Based on this, we identify several lines of enquiry and action for future research and policy.

Socio-demographic development and burden of mental, substance use disorders, and self-harm: An ecological analysis using the Global Burden of Disease study 2019

OBJECTIVES

Whether a country's level of development is associated with an increased or decreased burden of mental and behavioural problems is an important yet unresolved question. Here, we examined the association between the burden of mental and substance use disorders and self-harm with socio-demographic development along temporal and geographical dimensions.

METHODS

We collected data from the Global Burden of Disease study 2019, which uses robust statistical modelling techniques to calculate disease burden estimates where data are sparse or unavailable. We extracted age-standardized Disability Adjusted Life Year rates as a measure of disease burden for 204 countries and territories, as well as the Socio-Demographic Index, a measure of development reflecting income per capita, fertility rate and level of education. We tested the association between Socio-Demographic Index and Disability Adjusted Life Years for mental and substance use disorders and self-harm, between 1990 and 2019, and across six geographical regions as defined by the World Health Organization.

RESULTS

The association between Socio-Demographic Index and Disability Adjusted Life Years was heterogeneous across world regions for all mental and behavioural conditions. For substance use disorders and self-harm, these regional variations were further moderated by time period. Our findings were robust to down-weighing outlier observations, as well as controlling for other socio-demographic variables, and the number of data sources available in each country.

CONCLUSION

Based on data from the Global Burden of Disease study 2019, we demonstrated that the association between mental and substance use disorders and self-harm with socio-demographic development is dependent on geographical regions and temporal periods. This heterogeneity is likely related to geographical and temporal variations in socio-cultural norms, attitudes towards mental problems, as well as health care and social policies. Better knowledge of this spatial and temporal heterogeneity is crucial to ensure that countries do not develop at the expense of a higher burden of mental and behavioural conditions.

Paediatric use of emergency medical services in India: A retrospective cohort study of one million children

Background

Millions of children in low- and middle-income countries (LMICs) experience illness or trauma amenable to emergency medical interventions, but local resources are not sufficient to treat them. Emergency medical services (EMS), including ambulance transport, bridge the gap between local services and higher-level hospital care, and data collected by EMS could be used to elucidate patterns of paediatric health care need and use. Here we conducted a retrospective observational study of patterns of paediatric use of EMS services by children who used EMS in India, a leader in maternal and child EMS development, to inform public health needs and system interventions to improve EMS effectiveness.

Methods

We analysed three years (2013-2015) of data from patients <18 years of age from a large prehospital EMS system in India, including 1 101 970 prehospital care records across 11 states and a union territory.

Results

Overall, 38.3% of calls were for girls (n = 422 370), 40.5% were for adolescents (n = 445 753), 65.9% were from rural areas (n = 726 154), and most families were from a socially disadvantaged caste or lower economic status (n = 834 973, 75.8%). The most common chief complaints were fever (n = 247 594, 22.5%), trauma (n = 231 533, 21.0%), and respiratory difficulty (n = 161 120, 14.6%). However, transport patterns, including patient sex and age and type of destination hospital, varied by state, as did data collection.

Conclusions

EMS in India widely transports children with symptoms of the leading causes of child mortality and provides access to higher levels of care for geographically and socioeconomically vulnerable populations, including care for critically ill neonates, mental health and burn care for girls, and trauma care for adolescents. EMS in India is an important mechanism for overcoming transport and cost as barriers to access, and for reducing the urban-rural gap found across causes of child mortality. Further standardisation of data collection will provide the foundation for assessing disparities and identifying targets for quality improvement of paediatric care.

Changing trends in the profile of rodenticide poisoning

Background

Deliberate self-poisoning (DSP) is one of the leading causes of mortality and morbidity, with rodenticides being common compounds used by many victims. However, comprehensive data regarding the spectrum and outcome of rodenticide poisoning is scant.

Method

This retrospective study was conducted in the Emergency Department (ED) of a large tertiary care hospital in South India between January 2017 and December 2018. All patients with deliberate consumption of rodenticides were included in the analysis.

Results

During the study period, 1802 patients presented with DSP, among which 145 (8%) consumed rodenticide compounds. The mean (SD) age was 27.9 (10.7) years. Young adults (16-30 years) comprised 73% (106/145) of the study population. The majority (87%) were triaged as priority 2, while 10% were triaged as priority 1. Common rodenticide compounds consumed were yellow phosphorous (57%: 82/145), coumarins (12%: 17/145), zinc phosphide (19%: 27/145), and aluminum phosphide (1%: 1/145). A significant proportion of patients (18.6%) were under the influence of alcohol. Among the 73 males, 25 (34.2%) gave a history of co-consumption of alcohol. There was a history of previous DSP attempts in 6%. The majority (68%) of the patients were discharged alive from the hospital, and the in-hospital mortality rate was 9%. Age >30 years (adjusted OR: 2.2; 95% CI: 1.00-5.05; p value: 0.04) was an independent predictor of poor outcome.

Conclusion

Rodenticide compound consumption for DSP is prevalent in young adults and is associated with significant mortality, especially with yellow phosphorous poisoning. The current trend in our country of the increasing use of highly fatal phosphorous compounds over the innocuous coumarin derivatives is a cause of grave concern.

Factors Challenging the Spiritual Rehabilitation of Iranian Men Affected by Natural Disasters: A Qualitative Study

Spiritual health is one important dimension of human health. Natural disasters, however, can adversely affect human spiritual health. One of the undeniable requirements of disaster management is the spiritual rehabilitation of victims to help them recover to their pre-disaster health conditions. This study aimed to explore the factors challenging the spiritual rehabilitation of Iranian men suffering from natural disasters based on the experiences of key informants. The participants were 19 spiritual health experts in post-disaster spiritual rehabilitation. Participants were selected using a purposive sampling method until data saturation was reached. The data were collected through semi-structured interviews and analyzed using Granheim and Lundman (2004) content analysis method. The factors challenging men's spiritual rehabilitation were classified into 6 main categories and 16 subcategories. The extracted categories included (i) correcting victims' perspectives, (ii) describing God's characteristics, (iii) seeking help from God, (iv) strengthening spiritual beliefs, (v) psychological factors, and (vi) tranquility factors. Our findings identified the important factors challenging the spiritual rehabilitation of the men victimized by natural disasters, which needed to be considered by responsible organizations and health sectors. Particularly, the organizations in charge of disaster management should take necessary measures and plans during the post-disaster phase to restore people's spiritual health. Spiritual health, currently a neglected dimension of health, should be considered people's in parallel with physical, psychological, and social health dimensions. Our results can be helpful in developing action plans for delivering a comprehensive spiritual rehabilitation service, which would help to lead to the full rehabilitation of victims after natural disasters.

Media reporting of suicide in the bengaluru E-edition of three major indian dailies: An archival study

India has the world's largest newspaper market, with over 100 million copies sold daily. The media scapegoat, simplify, speculate, and sensationalize suicide-related news instead of signposting people to seek help. Suicide affects individuals, families, and communities and is worthy of responsible reporting. This study examined the quality of newspaper coverage of suicides from January to December 2017 in three popular English dailies in Bengaluru, South India. Three hundred and ninety-five online suicide reports were evaluated for compliance with the 2017 WHO recommendations for responsible suicide reporting by media professionals. The secondary data were obtained from digital newspaper archives and analyzed. A handful of the sampled articles met key recommendations. While reporting on suicide in the Indian media, three critical areas that require the most attention are reducing sensationalism, providing help-seeking information, and educating the public on suicide prevention without perpetuating myths.

Suicide in India during the first year of the COVID-19 pandemic

BACKGROUND

There has been substantial discussion as to whether the mental health and socio-economic consequences of the COVID-19 pandemic might impact suicide rates. Although India accounts for the largest proportion of global suicides, the early impacts of the COVID-19 pandemic on suicide rates in this country are unknown.

METHODS

National Crime Records Bureau (NCRB) data were used to calculate annual suicide rates for the period 2010-2020, stratified by sex and state. Rate Ratios (RRs) stratified by sex and state were calculated to estimate the extent of change in suicide rates.

RESULTS

Suicide rates in India generally showed a decreasing trend from 2010 until 2017, with the trend reversing after this period, particularly for males. Among males and females, the highest increase post 2017 was noted in 2020 (compared to 2017) (males: RR = 1.18 95% UI 1.17-1.19; females: RR = 1.05 95% UI 1.03-1.06).

LIMITATION

Suicide rates based on the NCRB data might be an underestimation of the true suicide rates.

CONCLUSION

Suicide rates in India increased during the first year of the COVID-19 pandemic, and although the increase in suicide rates, especially among males, predates the pandemic, the increase in suicide rates was highest in 2020, compared to increases in previous years. Further research is warranted to understand the potential ongoing impact of the COVID-19 pandemic on suicide in India.

Epidemiological Risk Factors of Suicidal Behavior and Effects of the Components of Coping Strategies on Suicidal Behavior in Medical Students: A North-Indian Institution-Based Cross-Sectional Study

Background  Mental stresses and adoption of poor coping strategies can be a cause of suicidal behavior in medical students.

Objective  The aim of this study is to evaluate the prevalence and risk factors of suicidal behavior, and effects of the components of coping strategies on suicidal behavior among medical students

Methodology  An institution-based cross-sectional study was conducted among medical students of a college located in North India for a period of 2 months from February to March 2021. A total of 531 study participants (calculated sample size) were selected, and then allocated proportionally to each academic year, both through stratified random sampling technique. Then, the participants were asked to complete a self-administered questionnaire consisting of sociodemographic characteristics, Patient Health Questionnaire-9, Suicidal Behaviors Questionnaire-Revised (SBQ-R), and coping inventory. A pretest was done to modify the coping inventory and then exploratory factor analysis was performed on it to classify the components of coping strategies. Chi-square test and multiple logistic regression analysis were used to determine the risk factors and their association with suicidal behavior.

Results  A total of 104 (19.6%) respondents had reported SBQ-R cutoff score > 7 and had suicidal behavior. The rate of lifetime suicidal ideation, plan, and attempt was 20.3, 10.3, and 2.3%, respectively, among medical students, with 1-year prevalence of suicidal ideation at 33%. The mean age of the participants was 21.26 years (standard deviation = 1.99). The identified risk factors significantly associated with higher suicidal behavior were depression (odds ratio [OR] = 9.6), dissatisfaction with academic performances (OR = 4.9), and coping with mental disengagement (OR = 4.6), while coping with supportive strategies (OR = 0.57) was investigated as a preventive factor for the suicidal behavior.

Conclusion  The prevalence of suicidal behavior is found to be highly alarming, revealing that depression and poor coping strategies are risk factors among medical students. The analysis recommends that quantification of the problems, treatment at an early stage, and proactive student counseling to help them embrace the appropriate coping strategies, should be the first steps in prevention of suicidal behavior.

Domestic violence in Indian women: lessons from nearly 20 years of surveillance

BACKGROUND

Prevalence of self-reported domestic violence against women in India is high. This paper investigates the national and sub-national trends in domestic violence in India to prioritise prevention activities and to highlight the limitations to data quality for surveillance in India.

METHODS

Data were extracted from annual reports of National Crimes Record Bureau (NCRB) under four domestic violence crime-headings-cruelty by husband or his relatives, dowry death, abetment to suicide, and protection of women against domestic violence act. Rate for each crime is reported per 100,000 women aged 15-49 years, for India and its states from 2001 to 2018. Data on persons arrested and legal status of the cases were extracted.

RESULTS

Rate of reported cases of cruelty by husband or relatives in India was 28.3 (95% CI 28.1-28.5) in 2018, an increase of 53% from 2001. State-level variations in this rate ranged from 0.5 (95% CI  - 0.05 to 1.5) to 113.7 (95% CI 111.6-115.8) in 2018. Rate of reported dowry deaths and abetment to suicide was 2.0 (95% CI 2.0-2.0) and 1.4 (95% CI 1.4-1.4) in 2018 for India, respectively. Overall, a few states accounted for the temporal variation in these rates, with the reporting stagnant in most states over these years. The NCRB reporting system resulted in underreporting for certain crime-headings. The mean number of people arrested for these crimes had decreased over the period. Only 6.8% of the cases completed trials, with offenders convicted only in 15.5% cases in 2018. The NCRB data are available in heavily tabulated format with limited usage for intervention planning. The non-availability of individual level data in public domain limits exploration of patterns in domestic violence that could better inform policy actions to address domestic violence.

CONCLUSIONS

Urgent actions are needed to improve the robustness of NCRB data and the range of information available on domestic violence cases to utilise these data to effectively address domestic violence against women in India.

Administrative data deficiencies plague understanding of the magnitude of rape-related crimes in Indian women and girls

BACKGROUND

This paper investigates trends in rape-related crimes against women and girls reported in the Indian administrative data from 2001 to 2018 to assess the burden of crime, describe sub-national variations, and highlight data gaps to address sexual violence effectively in India.

METHODS

Data on five rape-related crimes were extracted from the annual reports of National Crimes Record Bureau (NCRB), and included assault with the intent to outrage modesty of woman, rape, insult to the modesty of women, attempt to commit rape, and murder with rape/gang-rape. Rates for all categories combined, and for each crime were estimated for women and girls for India and its states. Trends for type of offender for rape, mean number of people arrested, and legal status of the cases was also assessed.

RESULTS

The rate of all rape-related crime increased from 11.6 in 2001 to 19.8 in 2018 per 100,000 women and girls. Most of the 70.7% increase in rate between 2001 and 2018 was post 2012 following a gang-rape and murder case in India's capital. The largest proportion of crimes was recorded as assault with the intent to outrage modesty of the woman, followed by rape. The cited offender in rape cases was for the majority a close known person (44·3%) or other known person (43·1%). By the end of 2018, only 9·6% of the cases had completed trials, with acquittals in 73% cases.

CONCLUSIONS

The wide variations in the yearly crime rates at state-level highlighted significant issues in data quality including under-reporting, non-comparability, possible bias in data reporting in NCRB, definition of rape-related crime in India, and access in reporting of crimes. Addressing barriers to reporting, improving quality and scope of administrative data recorded on sexual violence is urgently needed for India to meet SDG targets of eliminating all forms of violence against women and girls.

The national suicide prevention strategy in India: context and considerations for urgent action

India reports the highest number of suicide deaths in the world. At this time when the Indian Government is formulating a national suicide prevention strategy, we have reviewed the current status of suicides in India, focusing on epidemiology, risk factors, and existing suicide prevention strategies to identify key challenges and priorities for suicide prevention. The suicide rate among Indian girls and women continues to be twice the global rate. Suicide accounts for most deaths in the 15-39 years age group compared with other causes of death. Hanging is the most common method of suicide, followed by pesticides poisoning, medicine overdose, and self-immolation. In addition to depression and alcohol use disorders as risk factors, several social and cultural factors appear to increase risk of suicide. The absence of a national suicide prevention strategy, inappropriate media reporting, legal conflicts in the interpretation of suicide being punishable, and inadequate multisectoral engagement are major barriers to effective suicide prevention. A scaffolding approach is useful to reduce suicide rates, as interventions provided at the right time, intensity, and duration can help navigate situations in which a person might be susceptible to and at risk of suicide. In addition to outlining research and data priorities, we provide recommendations that emphasise multilevel action priorities for suicide prevention across various sectors. We call for urgent action in India by integrating suicide prevention measures at every level of public health, with special focus on the finalisation and implementation of the national suicide prevention strategy.

Emotion regulation difficulties, perceived parenting and personality as predictors of health-risk behaviours among adolescents

Health-Risk Behaviours (HRBs) are significant antecedent conditions of adverse health outcomes among adolescents, and their prevention requires an in-depth understanding of associated factors. Like any other behaviour, HRBs may be an outcome of a complex interplay between personal and situational factors that determines our responses. Among other factors, emotional tendencies, specific behavioural patterns, and psychosocial environment may be the significant factors working at different hierarchical positions within a system and guiding human behaviours, including HRBs. Previous studies have explored the role of these specific factors in developing and maintaining HRBs, but mainly among the adult population, and no conclusive results could be observed regarding their contribution to HRBs in adolescents. The present study explored the predictability of adolescents' engagement in HRBs with regard to three representations of the mentioned factors, i.e., emotion regulation difficulties, perceived parenting practices and personality traits. A total of 723 (Males = 440) adolescents (Mage = 16.05, SD = 1.1) provided relevant information on the standardized questionnaires. Structural equation modelling was applied to test the stated hypotheses. Analysis revealed that the adolescents who reported more difficulty regulating one's emotions, perceived parenting practice as maladaptive, scored high on neuroticism and low on conscientiousness, showed more engagement in HRBs than their counterparts. Further, the findings indicated that emotion regulation difficulties and perceived parenting practices are stronger predictors of HRBs than personality traits. Interventional programs targeting HRBs among adolescents should address specific facets of emotional dysregulation and sensitise parents about their role in moderating adolescents' HRBs.

The burden of suicide in Brazil: findings from the Global Burden of Disease Study 2019

INTRODUCTION:

Suicide deaths varies according to location, sex, and age. This study analyzed the Global Burden of Disease Study 2019 (GBD 2019) concerning suicide in Brazil.

METHODS:

This study described the mortality and years of life lost (YLL) due to premature death caused by suicide in Brazil in 1990 and 2019. The numbers, crude and age-standardized mortality rate (ASMR), and YLL were compared among Brazilian states, age groups, and sexes.

RESULTS:

There were 13,502 suicides in Brazil in 2019, 46.00% more than in 1990. The crude mortality rate increased 0.32%, while the ASMR declined -21.68% during the period. Crude and age-standardized YLL rates declined by -7.24% and -18.38%, respectively. In 2019, the biggest ASMRs were found in the South, whereas from 1990 to 2019, the ASMR declined in the South, Southeast, and Midwest, and increased in the Northeast. The number of suicides was higher among individuals aged 15-49 years, and suicide rates were higher among those aged over 70 years. From 1990 to 2019, an increase in the rate was found only of 10-14 years of age. Suicide was highest in men, except in the 10-14-year age group, ranking third in mortality among men of 15-34 years of age and fourth among women of 15-24 years of age.

CONCLUSIONS:

The ASMR and YLL for suicide declined since 1990, but suicide remains an important factor of mortality in the country. The South Region, men, elderly, and youth should be priorities in the implementation of suicide prevention strategies in Brazil.

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.

Suicidal ideation and behavior in youth in low- and middle-income countries: A brief review of risk factors and implications for prevention

Although global rates of suicide have dropped in the last 30 years, youth in low- and middle-income countries (LMICs) continue to be highly represented in suicide statistics yet underrepresented in research. In this review we present the epidemiology of suicide, suicidal ideation, and suicide attempts among youth in LMICs. We also describe population-level (attitudes toward suicide, socioeconomic, and societal factors) and individual-level clinical and psychosocial risk factors, highlighting specific considerations pertaining to youth in LMICs. These specific considerations in risk factors within this population can inform how multi-level prevention strategies may be targeted to meet their specific needs. Prevention and intervention strategies relying on the stepped-care framework focusing on population-, community-, and individual level targets while considering locally- and culturally relevant practices are key in LMICs. In addition, systemic approaches favoring school-based and family-based interventions are important among youth. Cross-culturally adapted multimodal prevention strategies targeting the heterogeneity that exists in healthcare systems, suicide rates, and risk factors in these countries should be accorded a high priority to reduce the burden of suicide among youth in LMICs.

Suicide prevention in the context of COVID-19: An Indian perspective

The ongoing COVID-19 pandemic has impacted the health and wellbeing of communities worldwide. Measures to limit transmission, have enhanced vulnerability of individuals to well identified risk factors associated with mental illness and suicide. These include a sense of loneliness, anxiety, depression, insomnia, PTSD, harmful alcohol and drug use. Given that the potential for increased rates of suicide persist, the suicide prevention agenda remains urgent and essential. The same is one of the cornerstones of resilience in a society that is facing an array of challenges due to the pandemic. In this article, we recommend few possible strategies for attenuating suicide risk amidst the COVID-19 pandemic with particular relevance to the Indian context.

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.

Fertility, economic development, and suicides among women in India

PURPOSE

Indian states at greater levels of economic development report more suicides. This relation appears stronger among women relative to men. We test the hypothesis, suggested in the literature, that conflict between rapid economic growth and inadequate female autonomy (approximated using total fertility rate) varies positively with female suicides.

METHODS

We used state-level data on female suicides for all 35 Indian states and union territories, from 2001 to 2011, from the National Crime Records Bureau. We specified, as our outcome, age-adjusted female suicides per 100,000 population per state-year. We retrieved data on key covariates, namely, gross state domestic product (GSDP) per capita, total fertility rate (TFR), and other control variables from multiple national surveys and publicly available data sources. We examined whether and to what extent age-adjusted female suicides (per 100,000 population) correspond with total fertility rate (lower TFR indicates greater female autonomy and vice versa) within the context of greater economic development (GSDP per capita). Linear longitudinal mixed effect regressions controlled for state-specific random intercepts, son preference (male:female sex ratio at birth), literacy gap (percentage difference between literate males and females), access to health systems (institutional deliveries), female to male employment ratio, and linear time trends.

RESULTS

At constant levels of GSDP per capita, a one unit decline in TFR corresponds with 0.27 fewer female suicides per 100,000 population (P value = 0.008). Sensitivity tests indicate that this relation does not hold for male age-adjusted suicides (per 100,000 population).

CONCLUSION

Our findings, if replicated, indicate that at constant levels of economic development, lower TFR (indicating greater female autonomy) may reduce suicide risk among women.

Suicide Prevention Mobile Apps for Indian Users: An Overview

Suicide is an issue of global concern. Mobile applications (apps), if found effective, could supplement suicide prevention efforts by addressing some of the barriers to help-seeking. This study aimed to review the nature of suicide prevention apps available for Indian users using the Android platform. Apps identified were broadly reviewed on general features, inclusion of educative elements, suicide risk assessment, and strategies to manage suicidal thoughts. The search terms “suicide,” “suicide prevention,” and “feeling suicidal” were used to search the Google Play Store from May to December 2020, and apps exclusively focusing on suicide prevention were identified and reviewed.

The initial search resulted in 492 apps, of which 43 met inclusion criteria and were further assessed. Fewer than half the apps included supplementary information to users on scientific, evidence-based content (32.55%), and only a few apps were reported to be empirically validated (11.62%). Approximately one-third of the apps intended for people at suicidal risk had an initial screening aspect (16.12%), and one-third of the apps intended for support providers had a suicide risk assessment tool (25.92%). Most apps (81.39%) included a suicide helpline number specific to the region where they were developed, but only a few (23.25%) included motivational elements to call helplines. Common therapeutic strategies suggested to manage suicidal thoughts included distraction, means restriction, environment safety, perspective-shifting strategies, and calming or soothing strategies. Several apps (39.53%) included therapeutic strategies through safety plans.

For apps to be used effectively for suicide prevention, they should include evidence-based content and motivational elements to call helplines, and and clinicians need to examine app features and content before recommending them for use by patients.

Hunger, fear, and isolation - A qualitative analysis of media reports of COVID-19-related suicides in India

BACKGROUND

India's suicide rates are among the highest in the world and may increase further as a consequence of COVID-19. There is a need to examine which pandemic related stressors may be contributing to suicide, in order to inform the deployment of suicide prevention strategies, for the current as well as future pandemics.

AIM

To understand pandemic related stressors contributing to suicide in India.

METHODS

We identified and conducted a thematic analysis of Internet media reports of COVID-19 related suicides in India between February 1, 2020 (2 days after the first COVID-19 case), and May 31, 2020, (the end of phase four of the nationwide lockdown).

RESULTS

Ten pandemic stressors spanning both disease and lockdown-related factors were identified in 291 suicides. Economic hardship was present in a third; other notable stressors were: fear of the virus; isolation; desperation to be connected with loved ones or return home; and craving for alcohol. Men and young people seemed particularly vulnerable to these stressors.

CONCLUSIONS

COVID-19 related suicides appear to be precipitated by social and economic adversities, mainly associated with containment strategies. These findings need to be confirmed by national suicide data. Suicide prevention strategies should mitigate the impact of recognized stressors in the long term, target high-risk individuals, and offer mental health care alongside containment strategies.

Psychological well-being and burnout amongst medical students in India: a report from a nationally accessible survey

Background

Medical students in India face multiple challenges and sources of stress during their training. No nationally representative survey has yet been undertaken. We undertook a cross-sectional national survey to assess substance use, psychological well-being, and burnout using CAGE, Oldenburg Burnout Inventory (OLBI), and the short General Health Questionnaire (GHQ-12). The survey was open to all medical students in India. Descriptive statistics along with chi square tests and Spearman’s correlation were performed.

Results

Burnout was reported by 86% of respondents for disengagement and 80% for exhaustion. Seventy percent had a score of more than 2 on the GHQ-12, indicating caseness.

Conclusions

This study reveals that medical students are going through exceptional stress when compared to their age-matched peers. More nationally representative studies must be conducted on a large scale to quantify the problem and to help design new interventions.

Importance of pesticides for lethal poisoning in India during 1999 to 2018: a systematic review

BACKGROUND

Poisoning is a major problem in India. However, there is little systematic information on the key poisons responsible for most deaths by geographical area and over time. We aimed to review the literature to identify the poison classes causing the greatest number of deaths in India over the last 20 years.

METHODS

We performed a systematic literature review in Medline, Embase and Google Scholar (1999-2018), and Indian online medical journals, to find papers that reported deaths from all forms of poisoning in India, with last search 20 April 2020. We included epidemiological studies, observational studies, randomised trials, interventional studies, and case series published from 1999 to 2018 that showed the number of deaths and autopsy studies indicating the specific poisons or poison classes. Studies providing the case fatality for specific poisons or classes, which enabled calculation of the number of deaths, were also included. We excluded deaths due to animal bites and stings, ethanol or methanol poisoning, and gas inhalation as well as papers reporting a single death (case study of single patient). We grouped the papers into 5-year intervals and identified the two most common poison classes in each paper. We used descriptive statistics to summarise the findings over time based on the causative poison and the location of the study.

RESULTS

We identified 186 papers reporting 16,659 poisoning deaths between 1999 and 2018. The number of publications per 5-year interval showed no clear trend over the period (48, 38, 67, and 36 for consecutive periods). Half of the deaths (n = 8338, 50.0%) were reported during the first 5 years of the study (1999-2003), the number of deaths declining thereafter (to n = 1714 in 2014-2018). Deaths due to pesticide poisoning (94.5%) were dominant across the study period compared to other classes of poison [hair dye paraphenylenediamine poisoning (2.6%), medicine overdose (1.4%) or plant poisoning (1.0%)]. Among the pesticides, aluminium phosphide was the most important lethal poison during the first 10 years before declining markedly; organophosphorus insecticides were important throughout the period, becoming dominant in the last decade as aluminium phosphide cases declined. Unfortunately, few papers identified the specific organophosphorus insecticide responsible for deaths.

CONCLUSION

Use of the published literature to better understand the epidemiology of lethal poisoning in India has clear limitations, including secular variation in publishing practices and interest in poisoning. Unfortunately, there are no long-term detailed, combination hospital and community studies from India to provide this information. In their absence, our review indicates that pesticides are the most important poison in India, with organophosphorus insecticides replacing aluminium phosphide as the key lethal poison after government regulatory changes in 2001 reduced the latter's lethality. Plant and hair dye poisoning and medicines overdose caused few deaths. Aluminium phosphide deaths mostly occurred in northern Indian states, whereas deaths from organophosphorus insecticide poisoning occurred throughout India. Paraquat poisoning has become a clinical problem in the last 10 years. Lethal pesticide poisoning remains alarmingly common, emphasising the need for additional regulatory interventions to curtail the burden of pesticide poisoning deaths in India. More detailed reporting about the specific pesticide involved in lethal poisoning will be helpful to guide regulatory decisions.

Primary mental health care for older persons in India: how age-inclusive are public policies?

The need to improve the primary mental healthcare system in India has gained increasing public health attention. Concomitantly, efforts to frame and develop appropriate public mental health care through legislation and related strategies and programmes have been undertaken. Because older people in India are particularly prone to mental health problems, this study explores the inclusiveness of Indian public policies in addressing the primary mental health care needs of older people from a cross-policy perspective. The basis of this thematic document analysis is 41 key national strategic documents (1999-2018) from different thematically grouped policy fields. In the context of population ageing, socio-economic challenges for older people and changing family norms, the policies delineate a pronounced interest in old-age-inclusive primary mental health care, whereas international policies are regarded as important reference points. While some of the policies address older persons as a vulnerable group in general, others delineate a more differentiated picture of the older population. Moreover, as new rights with implications for old-age mental health care, including community-based access to mental health care, have emerged, an integrated old-age mental healthcare policy spanning across sectors remains absent. Although old-age-inclusive primary mental health care is an emerging trend in India, its development as a cross-cutting policy issue remains in its infancy. Accordingly, unambiguous integrated policy approaches are needed to address the complex mental healthcare needs of older persons, and further research should be undertaken to focus on mental healthcare strategies and approaches at the primary care level.

Application of a Scorecard Tool for Assessing and Engaging Media on Responsible Reporting of Suicide-Related News in India

BACKGROUND

Each year there are more than 800,000 deaths by suicide across the world, while India alone accounts for one third of female suicides and one fourth of male suicides worldwide. Responsible media reporting of suicide is an important suicide prevention intervention at the population level. There is sufficient evidence to show that the way suicide is reported and portrayed in the media can have a significant impact on individuals experiencing suicidal thoughts and behaviors. Recognizing the important role of the media in suicide prevention, the World Health Organization (WHO) issued guidelines for responsible reporting of suicides by the media. The Press Council of India, in 2019 endorsed WHO's guidelines for media reporting of suicides, however there is no evidence that the Indian media is complying with these guidelines.

METHODS

To encourage responsible media reporting, we developed a scorecard to assess and rate media reports on suicide. We reviewed several resource documents that contained guidelines on responsible reporting of suicide. After consulting with a team of experts, we arrived at a scorecard that consisted of 10 positive and 10 negative parameters.

RESULTS

We applied the scorecard to 1318 reports on suicide from 9 English language newspapers, with the highest readership in India between the dates of 1 April to 30 June 2020. For the articles analyzed, the average positive score across all newspapers was 1.32 and the average negative score was 3.31.

DISCUSSION

The scorecard can be a useful tool to assess media reports on suicide and provide metrics for the same. It can facilitate improved monitoring and engagement with media organizations, who can quickly check their own reporting compliance to the WHO guidelines and compare how well they are performing compared to their peers over time.

A longitudinal study of perceived stress and cortisol responses in an undergraduate student population from India

Young adults entering college experience immense shifts in personal and professional environments. Such a potentially stressful event may trigger multiple psychological and physiological effects. In a repeated-measures longitudinal survey (N = 6 time-points) of first year cohort of residential undergraduate students in India, this study evaluates multiple psychological parameters: PSS14 (Perceived Stress Scale), K10 (distress scale) and positive mood measures, along with salivary cortisol levels. We find that compared to women, men showed significantly lower levels of salivary cortisol and also a decrease in perceived stress (PSS14) and distress (K10) with time. By contrast, women reported similar perceived stress and distress levels over time but had higher cortisol levels at the end of the academic year. Academic stress was reported by the students to be the most important stressor. This study highlights notable gender-/sex-differences in psychological and physiological stress responses and adds a valuable longitudinal dataset from the Indian undergraduate student cohort which is lacking in literature.