SUICIDE MORTALITY IN INDIA Vikram Patel, Chinthanie Ramasundarahettige, Lakshmi Vijayakumar, JS Thakur, Vendhan Gajalakshmi, Gopalkrishnan Gururaj, Wilson Suraweera, and Prabhat Jha, for the Million Death Study Collaborators, and in partnership with Centre for Global Health Research (Toronto, Canada) CGHR.ORG/SUICIDE Twitter: CGHR_org Prabhat.jha@utoronto.ca Key findings • About 0.2 million deaths at ages 15 years and older in 2010 were due to suicide. • 54% of female and 40% of male suicides occurred at ages 15-29 years. • A 15 year old south Indian male had a 3.5% risk of dying from suicide before reaching 80 years, in the absence of the other causes. • About half of suicide deaths were due to poisoning. • Age standardised suicide death rates at ages 15 years and older were two fold higher in rural areas than urban areas. • Suicide death rates vary markedly between states. CGHR.ORG/SUICIDE Twitter: CGHR_org 2 What’s new about this research? • Previous suicide estimates have used the National Crime Records Bureau numbers, which are based on police reports • These data could under-report suicide, as attempted suicide is a crime in India • The Million Death Study provides direct suicide estimates by age, gender, area and method of suicide from a nationally representative sample. CGHR.ORG/SUICIDE Twitter: CGHR_org 3 Crude suicide death rate based on NCRB data CGHR.ORG/SUICIDE Twitter: CGHR_org Year 4 How was the study done? • Nationally representative sample (Sample Registration System) • 6,671 of these small areas randomly chosen from all parts of India (each with about 1000 people per area) CGHR.ORG/SUICIDE Twitter: CGHR_org 5 How was the study done? 800 Registrar General of India field workers interviewed 122 thousand families of people who had died in 2001-2003 Written reports each coded independently by at least two physicians to attribute a probable cause of death (i.e., suicide) Calculated proportion of all suicide deaths by age, gender, and area within the study CGHR.ORG/SUICIDE Twitter: CGHR_org 6 How was the study done? Combined with national 2010 UN totals of deaths, and 2007-2009 state-specific SRS death rates Produced national and state estimates of rates and number of suicide deaths for 2010 CGHR.ORG/SUICIDE Twitter: CGHR_org 7 Deaths from all causes in India, 2010 Age at death Estimated number of deaths Childhood/ early adulthood* (0-29 years) 2.8 Million Middle age (30-69 years) 4.0 Million Old age (70+ years) 3.0 Million Total 9.8 Million * ~ 2 Million at ages 0-4 8 Age specific suicide death rates in India and in high-income countries - Men Suicide death rate per 100 000 population 40 35 30 25 20 15 10 Age standardised suicide death rate at ages 15 years or older (99%CI) 5 India 26.3 (24.5, 28.0) High income 21.8 (21.6, 22.0) 0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ Age(years) 9 Age specific suicide death rates in India and in high-income countries - Women Age standardised suicide death rate at ages 15 years or older (99%CI) Suicide death rate per 100 000 population 40 India 17.6 (16.1, 19.0) High income 6.8 (6.7, 6.9) 35 30 25 20 15 10 5 0 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age(years) 50-54 55-59 60-64 65-69 70+ 10 Risk of suicide is high among Indians Cumulative risk of suicide (%) Country Male Female India (2010) 1.7 1.0 US (2004-07) 1.6 0.5 Canada (2004-07) 1.2 0.4 UK (2004-07) 0.5 0.2 CGHR.ORG/SUICIDE Twitter: CGHR_org 11 Risk of suicide is higher in rural and southern India Region Percentage probability of death of a 15 year old person before reaching 80 years Male Female Rural 2.05 1.08 Urban 0.81 0.60 South India 3.51 1.76 Rest of India 1.16 0.70 Total 1.69 0.96 12 Risk of suicide deaths for men and women aged 15 years and above 13 Estimated suicide deaths by different regions Region Estimated suicide deaths x1000 (age standardised suicide death rate per 100,000) Male Female Rural 95.1 (31.5) 57.8 (20.4) Urban 19.7 (14.4) 14.3 (12.0) South India 50.6 (52.9) 29.5 (32.2) Rest of India 64.2 (18.7) 42.6 (13.3) 114.8 (26.3) 72.1 (17.5) Total CGHR.ORG/SUICIDE Twitter: CGHR_org 14 Risk of death from Suicide For Indians aged 15 years, the risk of dying before age 80 in the absence of other diseases: 17 of 1000 men will die of suicide 10 of 1000 women will die of suicide CGHR.ORG/SUICIDE Twitter: CGHR_org 15 Source: Dikshit et al, Lancet 2012 Age standardised suicide death rate per 100,000 Suicide death rates for selected statesaged 15 years or older 70 60 Men Women 50 40 30 20 10 0 CGHR.ORG/SUICIDE Twitter: CGHR_org Kerala Andhra Pradesh Delhi Bihar & Jharkhand India 16 Method of suicide among Indian men – aged 15 years or older Drowning (T=4, ASR=0.8) Burns (T=5, ASR=1.1) 4% Other (T=8.8, ASR=2.0) 8% 4% Poisoning (T=60.2, ASR=13.8) 35% 49% Hanging (T=37, ASR=8.3) T = estimated suicide deaths in 1000, CGHR.ORG/SUICIDE Twitter: CGHR_org ASR = age standardised suicide death rate per 100,000 17 Method of suicide among Indian women – aged 15 years or older Other (T=5, ASR=1.2) Poisoning (T=31.5, ASR=7.9) Drowning (T=5.4, ASR=1.3) 7% 8% Burns (T=13.4, ASR=3.3) 15% 44% 26% Hanging (T=17,ASR=4.2) CGHR.ORG/SUICIDE Twitter: CGHR_org T = estimated suicide deaths in 1000, ASR = age standardised suicide death rate per 100,000 18 Significant risk factors for suicide Men aged 15 to 69 years Odds ratio (suicide vs. other deaths) (99% CI) Education Secondary or higher 1•43 (1•1 - 1•8) Primary or middle 1•60 (1•4 - 1•9) Below primary 1•00 -- Region Southern 2•68 (2•3 - 3•1) Rest of India 1•00 -- Alcohol use Yes 1•84 (1•6 - 2•2) No 1•00 -- Residence CGHR.ORG/SUICIDE Twitter: CGHR_org Rural 1•45 (1•1 - 1•9) Urban 1•00 -- 19 Significant risk factors for suicide Women aged 15 to 69 years Odds ratio (suicide vs. other deaths) (99% CI) Education Secondary or higher 1•90 (1•4 - 2•6) Primary or middle 1•43 (1•1 - 1•8) Below primary 1•00 -- Region Southern 2•96 (2•4 - 3•6) Rest of India 1•00 -- Marital Status CGHR.ORG/SUICIDE Twitter: CGHR_org Widower/divorced/separated 0•64 (0•4 - 0•9) Never married 0•92 (0•7 - 1•2) Married/ remarried 1•00 -- 20 CONCLUSIONS • Large proportion of suicide deaths occur between the ages of15 to 29 years. • Many suicide death might be prevented by: - restricting access to pesticides - providing community or support services - providing easy access to services for mental illness associated with suicide - reducing binge alcohol drinking through higher taxation on alcohol CGHR.ORG/SUICIDE Twitter: CGHR_org 21 Million Death Study Collaborators Indian Academic Partners (in alphabetical order): 1. Department of Community Medicine Gujarat Medical College, Ahmedabad: DV Bala, P Seth, KN Trivedi 2. Department of Community Medicine Kolkatta Medical College, Kolkatta: SK Roy 3. Department of Community Medicine Regional Institute of Medical Sciences, Imphal: L Usharani 4. Department of Community Medicine S.C.B. Medical College Cuttack, Orissa: B Mohapatra 5. Department of Community Medicine SMS Medical College Jaipur: AK Bharadwaj, R Gupta 6. Epidemiological Research Center, Chennai: V Gajalakshmi, CV Kanimozhi 7. Gandhi Medical College, Bhopal: RP Dikshit, S Sorangi 8. Healis-Seskarhia Institute of Public Health, Navi Mumbai: PC Gupta, MS Pednekar, S Sreevidya 9. Apollo Institute of Medical Sciences & Research, Hyderabad: P Bhatia 10. St. John’s Academy of Health Sciences, Bangalore: A Kurpad, P Mony, M Vaz, S Srinivasan, A Shet, AS Shet, D Xavier, S Rathi 11. King George Medical College, Lucknow: S Awasthi 12. Najafgarh Rural Health Training Centre Ministry of Health Government of India, New Delhi: N Dhingra, J Sudhir, I Rawat (until 2007) 13. Regional Medical Research Center, ICMR Institute, Bhubaneshwar: AS Karketta, SK Dar 14. School of Preventative Oncology, Patna: DN Sinha 15. School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh: N Kaur, R Kumar, JS Thakur 16. Tata Memorial Cancer Hospital, Mumbai: RA Badwe, R Dikshit, M Mallath Lead Partners: 1. Office of the Registrar-General India, RK Puram, New Delhi India: C Chandramouli (Registrar General of India [RGI]), RC Sethi, B Mishra, S Jain (until 2008), DK Dey (until 2009), AK Saxena, MS Thapa, N Kumar, JK Banthia and DK Sikri (former RGIs) 2. Million Death Study Coordinating, Centre for Global Health Research (CGHR), Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Dalla Lana School of Public Health, University of Toronto, Canada: P Jha (Principal Investigator), R Jotkar, R Kamadod, S Rao-Seshadri, P Rodriguez, P Sati, J Sudhir, C Ramasundarahettige, W Suraweera Affiliated Partners: 1. Indian Council of Medical Research, New Delhi India: VM Katoch (Director General or DG from 2008), NK Ganguly (DG to 2008), L Kant, B Bhattacharya, B Shah, DK Shukla 2. World Health Organisation, Geneva and SEARO Office, New Delhi: T Boerma, A Fric, S Habayeb (former WHO Representative-India), S Khanum, CD Mathers, DN Sinha, N Singh, P Singh (Deputy Regional Director) 3. Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, England: N Bhala, J Boreham, R Peto, G Whitlock 22