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 Table of Contents  
Year : 2015  |  Volume : 31  |  Issue : 2  |  Page : 123-129

Suicide and crisis management

Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

Date of Web Publication6-Jan-2016

Correspondence Address:
B S Chavan
Department of Psychiatry, Government Medical College and Hospital, Sector-32, Chandigarh - 160. 030
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9962.173297

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Suicide among the general population is a major public health problem and thus is a cause of concern for India. Since suicide is the outcome of multiple factors including socioeconomic, cultural, religious, and political; intervention and prevention strategies will vary from region to region. The legal framework and guidelines in a country can influence the suicide rate by eliminating barriers to mental health services, by adopting and strictly implementing policies on access to firearms for persons with risk of suicide, providing services for treatment of substance abuse patients, and by training of school personnel so that they can identify and assist vulnerable youth in accessing help. Mental Healthcare Bill (MHCB), 2013, will soon become the guiding law for the treatment and rehabilitation of persons suffering from mental health issues. Although MHCB has been criticized on many fronts, it still has laudable provisions that attempt to address reducing treatment gap through the proposal of availability of minimum mental health facilities at primary health center, proposing comprehensive treatment facilities including rehabilitation and the proposal to remove attempted suicide from Section 309 of IPS, etc., which might contribute in suicide prevention and other mental health crisis situations.

Keywords: Crisis, Mental Healthcare Bill, suicide

How to cite this article:
Chavan B S, Tyagi S. Suicide and crisis management. Indian J Soc Psychiatry 2015;31:123-9

How to cite this URL:
Chavan B S, Tyagi S. Suicide and crisis management. Indian J Soc Psychiatry [serial online] 2015 [cited 2022 Oct 5];31:123-9. Available from: https://www.indjsp.org/text.asp?2015/31/2/123/173297

  Introduction Top

Farmers' suicide in India has been getting a lot of political and media attention. However, suicide among the general population as a whole should be a major cause of concern for India. Recently, the World Health Organization (WHO, 2014) estimated that approximately 800,000 persons in the world die due to suicide every year and many more make suicidal attempts.[1] In fact, suicide affects the whole family leading to prolonged bereavement and poor physical health. In 2012, WHO estimated that suicide was the second leading cause of death among persons aged 15–29 years,[2] suicide though reported from all over the world; it was estimated that about 75% of global suicide occurred in low- and middle-income countries as per figures released in 2012. In addition, across all ages, suicide accounted for 1.4% of all deaths worldwide, making it the 15th leading cause of death (WHO).[2]

Since suicide is the outcome of multiple factors including socioeconomic, cultural, religious, and political; the prevalence, causes, and intervention strategies will vary from region to region. India ranks 43rd in descending order of rates of suicide with a rate of 10.6/100,000 as reported in 2009 by WHO.[3] Recently, Patel et al. (2012) attempted to calculate the prevalence of suicide in India. The findings showed that in 2010, approximately 187,335 persons aged 15 years and above died due to suicide and this is about 3% of the total deaths reported in the study.[4] The author calculated that the rates of suicide in India among individuals aged 15 years and older/100,000 population is about 26.3 for men and 17.5 for women and about half of the suicides were due to poisoning, mainly pesticides. An earlier study by reported that suicide rate in India is increasing; between 1975 and 2005 it increased by 43% with higher rates in the southern states of Kerala, Karnataka, Andhra Pradesh, and Tamil Nadu (suicide rate of >15) as compared to Northern states of Punjab, Uttar Pradesh, Bihar and Jammu and Kashmir.[5] For planning effective intervention strategies, it is important to investigate the causes and methods of suicide in a given country. While Patel et al.[4] and many earlier researchers [6],[7],[8] reported that majority of the suicides were by consuming pesticides, others reported that hanging was the commonest method of suicide.[9],[10],[11]

  Suicide and Mental Healthcare Bill (2013) Top

The legal framework and guidelines in a country can influence the suicide rate by (i) eliminating barriers to mental health services, (ii) adopting and strictly implementingpolicies on access to firearms for persons with risk of suicide, (iii) providing services for treatment of substance abuse patients, and (iv) training of school personnel so that they can identify and assist vulnerable youth in accessing help. All these measures will be discussed below in detail in the light of provisions of the Mental Healthcare Bill (MHCB), 2013.[12]

The most significant provision in the MHCB (enlisted at serial no. 17) is to exclude attempted suicide from Section 309 of IPS. Section 124 (1) of MHCB states that any person who attempts to commit suicide shall be presumed, unless proved otherwise, to be suffering from mental illness at the time of attempting suicide and shall not be liable to punishment under the said section and in such cases the government shall have a duty to provide care, treatment and rehabilitation to such a person. This should motivate the affected person and caregivers to seek help rather than denying the attempt (in order to escape from the offence under Section 309 of IPS). Since the MHCB has not become a law as yet, the government has decided to decriminalize “attempt to suicide”[13] by deleting Section 309 of the Indian Penal Code from the statute book. Under the said section, a suicide bid is punishable with imprisonment up to 1 year, or fine, or both. The law commission recommended dropping Section 309 from the IPC after 18 states and 4 Union territories backed the recommendation of the law commission of India in this regard. This might prove to be very welcome step in reducing stigma attached with attempted suicides. Persons will no longer feel the need to hide their suicidal thoughts and would be encouraged to talk about them with others and hence would be able to seek professional help.[14] However, some states argue that decriminalizing “attempt to suicide” would handicap law enforcement agencies in dealing with persons who resort to fast unto death or self-immolation to pressurize the government or authorities to accept their unreasonable or illegitimate demands.

Thus there is a need for a clear distinction to be drawn between persons driven to suicide due to medical/psychiatric illness and suicide bombers who fail to blow themselves up or terrorists who consume cyanide pills to wipe out evidence; with a need for the initial category to be covered by a separate legislation.

The next important sections of MHCB that talk directly of reducing suicides and attempted suicides are Section 29 and Section 30 which say that government will take steps to plan and implement programs for promotion of mental health and prevention of mental illness for reducing suicides and attempted suicides in the country.

In order to understand these sections, it is important to know the causes of suicide and the persons who are at high risk so that targeted interventions can be initiated. Suicide is a complex phenomenon and has been viewed as the outcome of individual vulnerability and social stressors. Factors such as divorce, love affairs, extramarital affairs, and domestic violence increase the risk of suicide among women in India.[15],[16] Although risk factors might vary from individual to individual, finally it might be the development or presence of mental disorders leading to suicide. Studies from Europe and North America have reported that around 90% of those who die by suicide suffer with a mental disorder.[17],[18] Reports from the developing countries are limited. From India, two case control studies from Bengaluru [16] and Chennai [19] reported that 43% and 88%, respectively, had a diagnosable mental disorder. However, more recent studies from India report lesser rate of diagnosable mental disorders. A study by Chavan et al.[9] from Chandigarh showed that only 33.6% had psychiatric disorders and other risk factors were psychosocial stressors (60%), interpersonal conflicts (47.5%), financial stressors (8.8%) and about 23.7% reported drug and alcohol abuse. Alcoholism has been seen to play a significant role in suicide in India. In addition to high rates of drug and alcohol abuse from Chandigarh, the studies from Chennai and Bengaluru reported that around 30–50% of male who committed suicide were under the influence of alcohol at the time of act.[5],[16]

Prevention of suicide has been perceived as one of the most difficult and complex issues as a large number of factors such as social and environmental factors (e.g., unemployment, poverty, etc.,) are beyond the control of mental health professionals. However, in majority of the cases, suicide is the final outcome of long standing mental health issues thereby providing a window of intervention. Suicide prevention interventions have been classified as universal, selective or indicated.[20] In the universal interventions, the focus is on the whole population with the aim of reducing the risk across the entire population. In the selective interventions, the focus of intervention are the individuals who are at high risk of suicide whereas the indicated interventions are targeted toward persons who are already having suicidal thoughts or behavior. Evidence based strategies on suicide prevention [21] focus on enhancing mental health literacy, encourage help-seeking behaviors with a message that suicide is preventable and mental illness is treatable, restriction of access to lethal means (for example, gun control), restrictions on pesticides and to provide training programs for practitioners and other professionals, i.e., healthcare professionals, general practitioners, disciplinary force, media, and teaching staff.

Substance abuse and co-morbid depression: In addition to host of other factors, alcoholism plays a significant role in suicide in India. Various studies have found that around 30–50% of male suicides were under the influence of alcohol at the time of suicide.[16] In a study from Chandigarh, more than 23% of suicide victims had alcohol and substance abuse history.[9] Predisposing factors that might increase risk for suicide among individuals with alcohol dependence are aggression/impulsivity and alcoholism severity. Since the definition of mental illness under MHCB includes mental conditions associated with the abuse of alcohol and drugs, the treatment of substance abuse related mental health issues is likely to come in forefront and the government has to expand the facilities for treatment and rehabilitation of persons with substance abuse.

Prevalence of mental disorders among children has been reported to be 14–20% in various studies.[22] According to the World Health Report (2000),[23] 20% of children and adolescents suffer from a disabling mental illness worldwide and suicide is the third leading cause of death among adolescents.[15] Malhotra et al.[22] reported that the incidence of psychiatric disorders in the normal children group was 18/1000/year. The issue of childhood psychiatric morbidity is more serious in middle and low income countries because these countries have a much larger proportion of child and adolescent population; much lower levels of health indices; with poorer infrastructure and resources to deal with problems. There are limited child and adolescent mental health services in India and whatever exists is restricted to urban areas. Thus, majority of children with emotional or behavioral disorders are not getting the appropriate services.[24]

Thus focusing on prevention of mental illness and promotion of mental health is in keeping with the available literature. However, the MHC Bill is silent on how these will be achieved. In the absence of any blueprint this provision, though essential, will lose any significance in the long run. Training of school personnel so that they can identify and assist vulnerable youth in accessing help can be one such step that can serve both the purposes of prevention of mental illness and promotion of mental health. The revised District Mental Health Programme (DMHP)[25] proposes to collaborate and train the District Health Team (of National Rural Health Mission) in identifying and managing mental health problems in school children and running an outpatient service for children with more severe mental health problems. Hence, if implemented effectively it can help achieve the objectives of prevention of mental illness and promotion of mental health.

  Section 29 (2) - policies on Access to Means of Suicide Top

There is substantial evidence to support that ease of access influences method of choice. For example, overdose survivors indicated that they chose overdose because drugs were readily available in the household.[26] Similarly, it has been reported that more than half of suicides in rural parts of China are by pesticides or rat poison and suicide in the USA using firearms are committed by people with access to guns. Researchers have argued that restricting the access to means of suicide can be effective among persons with high lethality and impulsive behavior.[27] Many other researchers have also reported that the means of suicide was linked to the availability of methods.[28],[29]

In India, under the Insecticide Act (1968),[30] it is mandatory for any person who is desirous of manufacturing, selling or stocking any insecticide to get a license, and the offenders are liable for punishment which might include imprisonment which can extend up to 3 years and fine which can be up to 3000 rupees. Unfortunately, in the garb of pest control, any person from rural India can easily purchase pesticide which can be used as a mean of committing suicide by any of the family member who is experiencing a mental health problem. In addition to strict control by the government, the farmers need to be educated about the hazards so that the pesticide is kept under lock and key.

The Indian Government also has stringent law for possession of arms. All matters pertaining to arms and ammunition such as acquisition, possession, manufacture, sale, import, export, and transport are governed by the Arms Act, 1959, and the rules framed there under namely the Arms Rules 1962.[31] Anyone who is desirous of having a license for firearm has to state the reason of having gun, and the reason could be one's profession or threat to life. In case if the police finds the reason good enough, one can get a license. Although the gun control is reasonably strict in India, the use of firearms among youngsters is on the rise and thus there is need for more stringent control and public education.

As per Se ction 18 and Section 19 [refer to point numbers 1–12 of [Table 1], for the first time, Government of India through MHCB has tried to address the issue of lack of mental health facilities in the country. Under Section 18 of the MHCB,[12] seeking mental health will become the right of a person with mental illness and the government has committed to setting up mental health facilities which are affordable of good quality, available in sufficient quantity, geographically accessible, without discrimination and are proposed to be provided in a manner that is acceptable to persons with mental illness, their families and care-givers. In fact the government has further committed to provide a range of services including acute mental health services such as outpatient and inpatient services, rehabilitation facilities (in the form of half-way homes, sheltered accommodation, supported accommodation), and extending support to families and caregivers through home-based care and community-based rehabilitation facilities. The MHCB has also proposed to set-up child and old age mental health services. Through MHCB, government has proposed to provide mental health facilities at the level of Community Health Centers (CHCs) and district hospitals (DH). Each DH is expected to have adequate mental health facilities at par with general health services. However, it has not been specified whether there will be mental health professionals posted in the CHC or the medical officers posted in the primary healthcare would be trained to diagnose and treat mental illnesses. The review of the DMHP project has shown certain limitations to integrate mental health with general healthcare and this needs to be revisited before having unreasonable and over enthusiastic expectations.[32]
Table 1: Depicts various sections of MHCB which, directly or indirectly, have a bearing on suicide prevention and crisis management

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Another major area of concern in the delivery of mental healthcare is to look after homeless mentally ill persons. The MHCB has attempted to address this issue and has proposed that persons with mental illness living below the poverty line, or who are destitute or homeless shall be entitled to mental health treatment free of any charge at all mental health establishments run or funded by the government. Availability of essential drugs for common mental health problems at the primary healthcare level is another bold commitment by the government. All these provisions are welcome steps. However, it needs to be seen whether the government will have sufficient funds and conviction to create such comprehensive mental health facilities. Provisions in the Bill relating to the rights of the community care and independent living do not appear adequate. Details as to how the government should go about providing these services, budgets that need to be allocated and time frame within which these changes should be implemented are lacking.[33]

Earlier, the Government of India, through the National Mental Health Programme (NMHP) way back in 1982,[34] promised to ensure availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of population. However, even after 33 years of launch of NMHP, basic mental health facilities are beyond the reach of a common man. Some of the recent initiatives by the Government of India including proposal to extend DMHP to all the Districts of India, starting center of excellence for manpower production in mental health, up-gradation of Departments of Psychiatry in Medical Colleges so as to meet Medical Council of India criteria for starting Postgraduation in Psychiatry and starting M. Phil course in Clinical Psychology and Psychiatric Social Work as well as Diploma in Psychiatric Nursing provide some ray of hope.

  Crisis Management and Mental Healthcare Bill Top

Mental health crisis

A mental health crisis is an intensive behavioral, emotional or psychiatric response triggered by a precipitating event. If this crisis is left untreated, it could result in an emergency situation.[35] Mental health crisis is any situation in which a patient's behavior puts him at risk of hurting himself or others and the caregivers are not able to resolve the situation with the skills and resources available with them. In the field of mental health, a large number of factors can lead to crisis including aggression and violence, suicidal or homicidal behavior, drug overdose and intoxication, adverse drug reactions, acute psychotic reactions including delirium and interpersonal problems.[36],[37] Caplan (1964) identified four phases of crisis. They are as follows: Phase 1: Initial threat or triggering event where there is arousal and efforts at problem solving behavior increase, Phase 2: Escalation with increase arousal or tension, functional impairment ensues with associated disorganization and distress, Phase 3: Crisis where emergency resources both internal and external are mobilized and novel methods of coping are tried, and Phase 4: Personality disorganization where continuous failure to resolve the problem leads to progressive deterioration, exhaustion, and decompensation.[38] It may not be possible to predict the crisis in majority of the situations. However, certain warning signs such as sudden change in behavior, agitation, increased energy level; pacing, verbal threats, confusion, etc., might be the warning signs for impending mental health crisis. Even if the caregivers are able to predict mental health crisis, they might find themselves incapable of handling it and look for immediate help. Help in crisis can be offered in two different ways: At an early stage, when the person attempts to mobilize help as a part of adaptive coping, and later in decompensation phase when intervention by others becomes a matter of necessity to prevent further disorganization.[38] The mental health facilities are limited in India, particularly in the rural area and the primary healthcare facilities including local physicians in the vicinity refuse to help the persons with mental health problem due to limited expertise and fear of conviction due to stringent mental health legislation. Under MHCB, no person with mental illness can be treated in a health facility which is not registered and the facility under Section 2 (1) (0) includes all healthcare facilities except the residential place where person resides. In case a person with mental illness is treated in an unregistered facility, the treating doctor is liable to be punished under Section 117 of MHCB.

Further Section 103 is important for crisis management which says that emergency medical treatment, including treatment for mental illness, may be provided by a registered medical practitioner with the informed consent of the nominated representative to prevent serious harm to self or others or serious damage to property of self or others if such behavior is believed to be caused by mental illness. The emergency treatment generally shall not last for more than 72 h. This practically means that caregivers can seek treatment from any nearby physician or general health facilities for mental health crisis. However, in spite of legal sanctity to provide treatment in case of mental health emergencies, majority of the doctors can still refuse to offer help forcing the caregivers to use restraints (including chaining) till the patient is taken to an appropriate mental health facility. In-service training of medical officers working in primary healthcare facilities and strengthening of undergraduate psychiatry training should play a crucial role in helping a mentally ill person during mental health crisis.

In a country like India, there are many barriers in seeking mental healthcare. The barriers in seeking help in rural area include unavailability of mental health services, low literacy rates, sociocultural barriers, financial constraints, religious beliefs, and stigma. The barriers in seeking mental healthcare in urban areas include high cost of care, stigma, and low priority accorded to mental health. Other barriers include low political will of the government, difficulties in integrating mental health in primary health care and inadequate psychiatry training at undergraduate level. These factors result in a treatment gap which can be as huge as 82–96% even in metropolitan cities of India.[39] In such a scenario, provision of emergency services is a farfetched dream. Thus the provision of emergency care during mental health crisis by any registered medical practitioner.

[TAG:2]Summary and Conclusion[TAG:2]

Although, the MHCB has been criticized on many fronts including over regulation through mental health review commission, minimizing the importance of caregivers through the new concept of nominated representative and ignoring the importance of general hospital psychiatry unit; it still has laudable provisions. The attempt to reduce treatment gap through the proposal of availability of minimum mental health facilities at primary health center, proposing comprehensive treatment facilities including rehabilitation and the proposal to remove attempted suicide from Section 309 of IPS are welcome steps.

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Conflicts of interest

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