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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 37  |  Issue : 4  |  Page : 413-417

Nature and drivers of suicide in a rural community of Western Maharashtra


1 Bapu Trust for Research on Mind and Discourse, Pune, Maharashtra, India
2 Professor Emeritus, Swiss Tropical and Public Health Institute (Swiss TPH) and University of Basel, Switzerland
3 Assessment and Impact Measurement Team, Tata Trusts, Switzerland
4 Foundation for Research in Community Health, Pune, Maharashtra, India

Date of Submission29-May-2020
Date of Decision30-Sep-2020
Date of Acceptance25-Oct-2020
Date of Web Publication20-Jul-2021

Correspondence Address:
Dr. Nerges F Mistry
Foundation for Research in Community Health, 3 and 4, Trimiti B Apartments, Lane No. 1, Anand Park, Aundh, Pune - 411 007, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_137_20

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  Abstract 


Context: The National Crime Records Bureau reports that 134,516 deaths result from suicide in India every year. Maharashtra accounts for 13.4% of the total reported suicides. Aims: This documentation study in the framework of a community mental health program (CMHP) aimed to identify local features of suicide in a rural community, namely sociodemographics and drivers of suicide. Settings and Design: The study was conducted in a community of rural Purandhar block in Western Maharashtra from January 2014 to March 2016 where a CMHP was ongoing since 2013. Data were collected as a part of process documentation through its local community health workers (CHWs). Subjects and Methods: CHWs involved in the program were interviewed, and data were analyzed manually. Results: Seventeen completed and seven attempted suicides who were not a part of the ongoing CMHP among the population were documented. Majority were men under 30 years of age. Pesticide consumption was the most common method of self-harm, and domestic strains were the major driver for suicides. Conclusions: The local pattern of suicidal behavior and its context are relevant for consideration in suicide prevention plans responsive to culture-specific features of suicide.

Keywords: Farmer suicides, Maharashtra, mental health, rural community


How to cite this article:
Sharma R, Weiss MG, Sule N, Mistry NF. Nature and drivers of suicide in a rural community of Western Maharashtra. Indian J Soc Psychiatry 2021;37:413-7

How to cite this URL:
Sharma R, Weiss MG, Sule N, Mistry NF. Nature and drivers of suicide in a rural community of Western Maharashtra. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Nov 30];37:413-7. Available from: https://www.indjsp.org/text.asp?2021/37/4/413/321879




  Introduction Top


Suicide is the eighteenth leading cause of mortality globally.[1] The National Crime Records Bureau (NCRB) reported 10.2 per one lakh as the all India suicide rate, amounting to134,516 suicides in 2017.[2] A comprehensive WHO study, however, reported a much higher suicide rate of 16.5 in India in 2016.[3]

Maharashtra accounted for 13.4% (17,972) of the total NCRB-reported suicides in the country.[2] A high number of male and youth suicides and suicides attributed to domestic problems, illness, and suicide by hanging and by consuming pesticides were also reported in other states.[2]

The interplay of social, psychological, and cultural factors should be acknowledged in efforts to explain suicidal behavior. Mental health studies emphasize a strong association between mental disorders and suicides.[4],[5] Stigma and fear of societal condemnation may lead to the hiding of information and delay help seeking.

A Community Mental Health Program, named Jan-Man Swasthya Programme (JMSP) was initiated in 2013 in a rural community of 55,000 people in Western Maharashtra. Locally recruited and trained community health workers (CHWs) provided information on suicide and nonfatal suicidal behavior in persons from the program areas who were not a part of the JMSP.

Awareness of local contexts of suicide is required to ensure that prevention efforts are well grounded and relevant for prevention, and for guiding and implementing empathic and effective community care for associated mental health problems, regardless of whether suicidal ideation or behavior was a feature of their presentation.[6] A plan for documentation was developed to assess the features of suicide in the rural community, clarify the sociodemographic profile of the victims, and identify drivers of suicide.


  Subjects and Methods Top


Data concerning completed suicides and attempts were collected from 28 villages in the study area for the period from January 2014 to March 2016.

CHWs received information about suicidal behavior through community contacts, family members, or individuals who had engaged in nonfatal deliberate self-harm. A project researcher was notified through a formal process of the documentation involving group discussions, interviews, and informal interactions with the CHWs. The four CHWs were local women who were residents of the community and were trained in screening and identifying persons in the community with mental health-care needs. An unobtrusive approach for data collection was conscientiously adopted to protect individuals and their families from revisiting the emotional distress of the suicide or suicide attempt. Owing to limitations in the knowledge base and its complexity, suicide prevention in the community was not included among program activities of the JMSP. Nevertheless, these cases were documented thoroughly to clarify contexts of suicides and related for subsequent inclusion in the ongoing program. Help was provided in terms of counseling and psychoeducation for the identified individuals and caregivers. Information about suicide events and behavior was captured by a researcher through a formal process of documentation in the program through group discussion and informal interviews with the CHWs. A total of 24 short interviews or interactions were obtained by the CHWs, one for each event reported. In addition, several group discussions also took place, monthly in all months where such events were reported, to elicit further information about these events. These group discussions involved the CHWs, program team, and the researcher. Affected individuals – family members, relatives, etc., – did not participate in these discussions. All notes were manually recorded. If multiple reasons for suicide were reported by different respondents for the same case, those reported by the source closest to the index case were regarded as authoritative. If family or relatives of the index case of attempted suicide were unavailable or unable to be interviewed, information was collected from neighbors or others in the community who were aware of the event and its details. The narratives were recorded by the CHWs manually and shared with the program and research team.

Data were analyzed manually. Topical themes were formulated in advance to guide the analysis, which described the profile of fatal and nonfatal suicides in the community. Narrative data were elicited during the CHW visits and coded with respect to these topical interests: (a) sociodemographic profile of the individuals, (b) reasons for suicide, (c) social contexts of acute and chronic stressors, (d) methods of suicide, (e) personal or family history of suicidal behavior, and (f) prior contact with the CHWs. Themes referring to “social context: acute and chronic stressors” were formulated based on data over the course of the analysis.

Ethics clearance was obtained for the study of this program documentation from the organization's Institutional Research Ethics Committee (IREC/2014/20/05).


  Results Top


A total of 17 completed and 7 attempted suicides were identified (but not recorded in the JMSP) between January 2014 and March 2016. Features of suicide are summarized in [Table 1] and a comparison between completed and attempted suicides in [Table 2].
Table 1: Sociodemographic profile and suicide features of individuals (n=24)

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Table 2: Some prominent features of comparison between completed and attempted suicides

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Sociodemographic profile (gender, age, marital status, occupation, and education)

Most suicides were by men (19/24), and a substantial proportion was under 30 years of age (11/24). The majority of cases were married (15/24), were farmers (16/24), and had mid-level education (22/24). Details of socioeconomic status could not be gauged accurately from the indirect sources. For the socioeconomic profile of the individuals, the CHWs relied on indirect sources, e.g., relatives, neighbors, and community residents. Information that could not be gauged accurately by the researchers was not recorded. The designation of “mid-level education,” which was reported most frequently, refers to schooling up to the eighth standard.

Reasons for suicide

Domestic tensions were most frequently reported (21/24) as the chief reason for suicidal behavior. These were typically referred to disturbed domestic situations, extramarital affairs, and alcohol addiction.

People think extramarital affairs in rural areas are rare but that's not true. Almost every 10th house in the village has these issues. This leads to chaos and affects children as well. [A]

Alcohol addiction and domestic violence is an everyday affair in our villages. Some men drink out of habit, some to allay tensions. They gradually become addicted and beat up their families. [B]

  • Social contexts: acute and chronic stressors


Domestic violence was reported in 3 of the 24 cases. They were all associated with male alcoholism. Twenty-three out of 24 cases were associated with reported chronic stressors. These chronic stressors were typically exacerbated by a precipitating event (13/23). Detailed information about a specific trigger in the remaining 10 cases was unavailable. Only one case was reported to have been triggered by an acute stressor (bereavement). The context indicated in the following account, however, is more typical:

A 23-year-old man had regular fights with his parents over his alcoholism. He was a daily wage labourer, and his parents were tense about his employment, his marriage plans and his alcoholism. One evening they had a major fight, and he drank excessively. He committed suicide the same night by laying down on the railway track. I had visited the house, but nobody mentioned alcoholism or domestic fights. These are regular affairs here, so people do not take them seriously. [B]

  • Previous attempt or family history of suicide


Ten out of 17 cases of suicide followed a nonfatal attempt, and the time lag from the prior attempt ranged from 10 days to 1 month.

Family history was noted in three cases of attempted suicide, and transgenerational patterns of distress appeared to play a role for some.

One man's father committed suicide when he was 8-year-old; both parents and the son were HIV positive. Post father's death, his mother developed schizophrenia. She would talk to herself and act very strange. The boy was very sad and attempted suicide by consuming pesticide. [C]

Methods of suicide

The most common method of suicidal self-harm was the impulsive consumption of pesticide (10/24) readily available in an agrarian community.

The pesticides are easily available in the homes, so they are within the reach of everybody in the household. Whenever there is a fight or somebody is angry, they can reach for a bottle and end their lives. [C]

The presence of a railway track near the community provided another opportunity for deliberate self-harm.

The railway track also serves as a place where people run off when they are angry or drunk. They lie there in the night, and their bodies are often found and identified the next morning.[A]

If contacted and help offered by community health workers during visits

The CHWs had contact with 13 cases, including five who attempted suicide and eight who subsequently completed suicide. They were contacted during awareness meetings or home visits but refused to participate. They explained their refusal saying they were not “pagal” (crazy), or they denied need for any help. The remaining 11 persons were unavailable and could not be contacted.

There were cases where the individual had certain issues (depression, anxiety), and we informed them of the available help. We were typically asked, “Do you think I am mad?” Or they would say, “I don't have any mental health issues, so why should I come to the programme?” This local (stigmatised) notion of “mental” made it very difficult to convince people to enrol in the programme.[A]


  Discussion Top


Even after excluding those who had enrolled in the local program, we identified 17 completed suicides in a population of 55,000. This corresponds to an annual rate of 13.7 per 100,000. This figure is almost identical to the rate of 13.4 per 100,000 reported by the NCRB report for Maharashtra for the year 2018 and is well over the national average rate of 10.2. Youth suicides (under 30 years of age) were notable in our population, consistent with national data.[7],[8],[9]

The role of male alcoholism and domestic violence were notable in the community. This suggests that timely identification of such individuals, recognition of the risk of suicidal self-harm, and the value of treatment are all relevant for effective suicide prevention. Innovative strategies for enhanced de-addiction programs are needed, beginning with school-level programs to promote awareness and reduce risk. Suicide awareness curricula in schools, skills training programs focusing on problem-solving and coping, screening, gatekeeper training, and psychosocial counseling to help cope with domestic discord are some prevention strategies that have been suggested.[10]

Chronic psychosocial stressors with some precipitating event were found to be the most prevalent reason for suicide attempts, consistent with reports from diverse rural areas of India.[11],[12] Although financial strains resulting from debt, high education costs, and medical expenses were noted, consistent with experience in the debt-burdened Vidarbha region of Maharashtra,[13] the stress driving suicidal behavior in our project area was primarily domestic tensions. A better local economy,[14] which is supported by measures mitigating agrarian distress and water insecurity due to low rainfall, and access to industrial employment opportunities explain the better economic condition in the area.

Pesticide consumption was the most common method of suicidal behavior, a finding similar across rural studies in India.[15] Ways to improve community awareness and practices for safe storage and use of pesticides are needed. Innovative measures, such as centralized community storage, may limit immediate access and deter impulsive use of pesticides for self-harm.[16]

The short time between a prior suicide attempt and subsequent suicide highlights the need for training and vigilance of CHWs to recognize the salience of suicidal behavior as a risk factor for completed suicide. Assessment, supportive counseling, case identification, and treatment of mental health problems are required. Efforts to enhance attentiveness to suicidal communications should identify people at risk.[17] Nondisclosure of suicide by families is common as a result of the criminalization of the act. A well-recognized tendency to avoid mental health services because they are stigmatized and considered appropriate only for “crazy persons” (pagal), was also a notable barrier to seeking care.[18] Decriminalizing suicide in the recent Mental Health Care Act 2017, which was implemented in July 2018, is expected to improve access and use of mental health-care services.[19]

Chronic illness is widely recognized[20] as a driver of suicide, and it was a notable stressor in one of our cases. Better integration of medical and mental health services is therefore needed so that training of medical practitioners enables them to recognize and address potentially life-threatening psychosocial aspects of such illnesses.

Although improving access and removing demand-side barriers to mental health care are priorities, reducing suicide in the population is more than a matter of closing the treatment gap. Although academic research in suicidology is appropriately concerned with biological determinants,[21] psychological, social, political, economic, and cultural factors are more immediately relevant for public health interventions.


  Conclusion Top


The local pattern of suicidal behavior and its context are relevant for consideration in suicide prevention plans responsive to culture-specific features of suicide.

Limitations

Reliance on indirect information may have prevented the consideration of additional relevant factors. Although the study area is relatively circumscribed, and findings may have limited generalizability, the approach for monitoring locally relevant data on suicides and attempts is widely applicable and relevant in many other local community settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO. WHO Suicide Data. World Health Organization. Available from: http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/. [Last accessed on 2020 May 29].  Back to cited text no. 1
    
2.
National Crime Records Bureau, Ministry of Home Affairs. Accidental Deaths & Suicides in India 2018. 2018. Available from: https://ncrb.gov.in/. [Last accessed on 2020 May 29].  Back to cited text no. 2
    
3.
World Health Organization. Global Health Estimates 2016: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2016. World Health Organization; 2018. Available from: https://apps.who.int/gho/data/view.sdg. 3-4-data-ctry?lang=en. [Last accessed on 2020 May 29].  Back to cited text no. 3
    
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Nock MK, Hwang I, Sampson N, Kessler RC, Angermeyer M, Beautrais A, et al. Cross-national analysis of the associations among mental disorders and suicidal behavior: Findings from the WHO World Mental Health Surveys. PLoS Med 2009;6:e1000123.  Back to cited text no. 4
    
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Henriksson MM, Aro HM, Marttunen MJ, Heikkinen ME, Isometsä ET, Kuoppasalmi KI, et al. Mental disorders and comorbidity in suicide. Am J Psychiatry 1993;150:935-40.  Back to cited text no. 5
    
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Rane A, Nadkarni A. Suicide in India: A systematic review. Shanghai Arch Psychiatry 2014;26:69-80.  Back to cited text no. 7
    
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Pitman A, Krysinska K, Osborn D, King M. Suicide in young men. Lancet 2012;379:2383-92.  Back to cited text no. 8
    
9.
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10.
Gould MS, Greenberg T, Velting DM, Shaffer D. Youth suicide risk and preventive interventions: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 2003;42:386-405.  Back to cited text no. 10
    
11.
Chowdhury AN, Banerjee S, Brahma A, Hazra A, Weiss MG. Sociocultural context of suicidal behaviour in the sundarban region of India. Psychiatry J 2013;2013:486081. Available from: https://www.hindawi.com/journals/psychiatry/2013/486081/. [Last accessed on 2020 Mar 02].  Back to cited text no. 11
    
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13.
Dongre AR, Deshmukh PR. Farmers' suicides in the Vidarbha region of Maharashtra, India: A qualitative exploration of their causes. J Inj Violence Res 2012;4:2-6.  Back to cited text no. 13
    
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Roy A. Vidarbha, Marathwada Lag Far Behind Mumbai, Pune. Times of India; 2016. Available from: http://timesofindia.indiatimes.com/city/nagpur/Per-capita-income-Vidarbha-Marathwada-lag-far-behind-Mumba i-Pune/articleshow/46602267.cms/. [Last accessed on 2020 Mar 02].  Back to cited text no. 14
    
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Mohanraj R, Kumar S, Manikandan S, Kannaiyan V, Vijayakumar L. A public health initiative for reducing access to pesticides as a means to committing suicide: Findings from a qualitative study. Int Rev Psychiatry 2014;26:445-52.  Back to cited text no. 16
    
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