Data Gaps: Is India's Highest Suicide Rate Because Of Better Reporting Or Rising Distress?

This story is part of our ongoing Data Gaps series, which highlights shortcomings in data of public interest. In this story on data gaps in India's sucide reporting, we analyse three trends that data from the Accidental Deaths and Suicides in India, 2021, show:

• The suicide rate is the highest since India began publishing this data in 1967, with 12 suicides per 100,000 people
• The rate of deaths by suicide were highest in developed states like Kerala and Telangana, at 27 suicides per 100,000 population
  
• 72.5% of those who comitted suicide were men
  

How are suicides reported?

A death by suicide is defined as the deliberate termination of life. For a death to be a suicide, it should be an un-natural death, the desire to die should originate within the person, and there should be a reason for ending their life, according to the National Crime Records Bureau.

When a death is deemed an unnatural death, the police are called, they file a First Information Report (FIR), which is transferred to the executive magistrate (like an additional district magistrate or the police commissioner), who undertakes and heads the entire investigation. This investigation comes under Section 174 of the Code of Criminal Procedure, related to inquiring about and reporting a suicide, explained advocate Chinmay Jawale who practices at the Bombay High Court.

An Indian Police Service (IPS) officer from the Maharashtra cadre explained that when a body is found, the police look for the cause of death. They first do a spot panchama to note down their first impressions in front of panchs (witnesses). The body is then taken to a government facility, where a government doctor performs an inquest panchnama and examines the body in front of witnesses. The doctor conducts a post mortem to determine the cause of death, and sends the internal organs (called viscera) to a laboratory for analysis, if they find anything suspicious. The police investigation begins if a case is registered, based on the postmortem report.

"​​Subsequently, after the investigation, if there is nothing more than the circumstances which led to the suicide, and if the police is satisfied that there is no foul play, then it will be closed as a suicide case," said N. Ramachandran, Former Director General of Police (Assam & Meghalaya) and the founder of the Police Foundation of India, a think-tank for police reform. "In case the relatives suspect anyone for abetting the suicide then that angle is investigated and a separate case of abetment to suicide is registered."

A separate case is also registered against the husband when a married woman has died by suicide within seven years, under Section 498A (husband or relative of husband of a woman subjecting her to cruelty), Ramchandran explained.

Issues with reporting death by suicides in India

Lakshmi Vijaykumar, a consultant psychiatrist and founder of SNEHA, an NGO in Chennai for the prevention of suicides, points to three reasons for underreporting of suicides: lack of medical certification of deaths, stigma associated with mental health, and criminalisation, not just in terms of reporting of sucides but sometimes also in the denial of insurance if the death is by suicide.

Many studies (2020, 2018) have pointed out that India has been undercounting suicides due to a lack of registration of deaths and medical certification of deaths. The Global Burden of Death study (2018) found that India's system of death certification covered only 22.5% of deaths, and that this number varied across states, from 43% in Tamil Nadu to 3.4% in Bihar.

In the United States, a medical examiner, who is a forensic specialist or pathologist, is called to the scene of death, and performs an autopsy to medically certify the cause of death. In India, the autopsy is done by any graduate with a medical degree rather than a specialist.

The Indian death certificate, unlike US death certificates, does not record a medical opinion regarding the manner of death. Even though in both the US and Indian systems, there are medico-legal autopsies, death scene investigation in India is the domain of the police or magistrate, and not of forensic medicine specialists. They can only weigh in when their inputs are sought by the police, according to this 2015 study by the Army College of Medical Sciences in Delhi.

This could lead to an underreporting of suicides as suicides could be registered as a natural death, especially in the case of poisoning.

Cases in which death is by hanging, jumping or drowning are reported more often, while poisoning cases are underreported, said Vijaykumar. Families also often pressure the police to say it is a case of accidental poisoning as they do not want to have the societal stigma of suicide attached to their family.

Keeping the reporting of suicide under the police also criminalises it in the eyes of the people, which makes them less likely to report a case.

Other experts point to how underreporting can take place in the NCRB itself. "Under reporting can happen in two ways. One is that the family does not report (the death) and the other is when the FIR is registered but the police station is unable to share the data with NCRB in time for reporting," says Rakhi Dandona, a professor of health metrics at the think-tank, the Public Health Foundation of India. As the NCRB does not give information about how many police stations send data to them, "we are not sure whether suicides have really gone up or just that more data is coming from more police stations across the country."

That said, stress, anxiety and sleeplessness due to the Covid-19 pandemic, and its impact on household income and loss of jobs, meant more people's mental health was impacted and they were reaching out to doctors, counsellors, psychiatrists and helplines, IndiaSpend reported in September 2020.

We have reached out to the NCRB to ask for clarifications on the data and on the underreporting of suicide cases. We will update the story when we receive a response.

Do developed states have more suicides?

"When you look at suicide deaths, the highest suicide rates are in the south. In central India, including Maharashtra, Madhya Pradesh and Rajasthan, you have "middling suicide rates", and the rate falls up north, in Uttar Pradesh and Bihar," said Vikas Arya, a research fellow in Mental Health at the University of Melbourne.

Data from the Global Burden of Disease study that used data from the Sample Registration System, which records all births and deaths in India, between 1990 and 2016, instead of NCRB data, found the same pattern--a high rate of suicide in southern states and a lower rate in northern states.

Experts like Arya point out that south and central India have better reporting infrastructure, compared to resource-poor northern states.

There is also more societal pressure in these states to have a successful life. "The thing is that a state with a high level of education also brings a higher level of expectations. And when those expectations are unmet the frustration level is higher," said Vijaykumar.

A 2019 study from the University of Melbourne showed that more economically developed states had three to four times higher rates of death by suicides than less economically developed states, but only a part of this could be attributed to better registration of suicide cases. The study said that other factors, including higher levels of male unemployment and higher literacy rates were linked with higher risks of suicide.

Missing women dying by suicides

In 2021, a little more than a quarter of suicide victims were women. Of females who died by suicide (45,026), the most (23,178) were housewives, followed by students (5,693), according to the NCRB report on Accidental Deaths and Suicides in India, 2021.

In 2021, 26% of women who died by suicide, died by poison. Experts point out that as more women use poison as a means of suicide, there are chances to this can be ruled as an accident, in absence of a proper investigation.

Another reason for underreporting is that a married woman's death by suicide could mean legal action against the husband and in-laws under the Dowry Act, incentivising families to not report female deaths.

It is also possible that some families may be concerned that a suicide death investigation may uncover abuses or sexual violence, potentially creating incentives for deaths to be classified as either natural deaths or accidents, according to a 2020 study by the Translational Health Research Institute.

"I think under-reporting is a pervasive problem especially when it comes to women's suicide," says Vijaykumar. "The explanation is always the same, they will say, 'she had stomach pain but did not know how much medicine to take or she didn't know that it was poison'."

Despite the underreporting, "in India, more young women die by suicide than anywhere else in the world," says Priti Sridhar, the CEO of the the Mariwala Health Initiative for mental health funding & advocacy. She calculates the suicide rate amongst women in India at 6.6 per 100,000, compared to the global suicide rate for women of 5.4 per 100,000 females.

The global burden of disease study found an additional 802,684 deaths by suicide (333,558 male and 469,126 female), between 2005 and 2015, when compared to data from the NCRB for the same period. It showed that the average under-reporting was 27% for males per year, and among females, the average under-reporting was 50% per year.

Dandona said that unclear reporting on deaths by suicide means it is harder to design interventions to reduce suicides among Indian women. "World over there are interventions that show that if you educate women, they get more empowered. And if they get more empowered, they take more control of their life, they can do things on their own," Dandona said, adding that this would suggest that south Indian states would have a lower rate of female suicide.

Improving data on suicides

India has committed to achieving the Sustainable Development Goal of a one-third reduction in the suicide mortality rate by 2030, for which India needs better quality data not just to track the change in the rate, but also to design interventions for its reduction.

India decriminalised attempt to suicide in 2017 under the Mental Health Care act, which protects the rights of a person with mental illness, and provides for access to treatment.

In line with this decriminalisation, experts suggest that data on suicide not be under the police but under the health system. "Under the current system suicides are reported by the police and NCRB, which makes it a crime, there is under reporting due to this and reporting will improve if data was collected as part of health systems," says Sridhar. "Death by suicide should be seen as a health indicator…One cannot work on suicide prevention, because you don't have enough information to design effective strategies."

Experts say that if data are to be under the police, then the system needs to be improved. For instance, amongst the most reported reasons for suicides are personal reasons, including love affairs, domestic issues and family issues. "We have to depend on the judgement of the policeman--whether he considers a love affair as a personal reason or mentions it separately," said Dandona. "We need to train the police to collect better and uniform data by creating better forms, and by training them on collection of information."

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