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Power of Means Reduction in Suicide Prevention

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By Dr Shalini Mittal

Claiming thousands of lives each year, suicides have become a global public health concern. The World Health Organization too has recognized suicide among the leading causes of death worldwide. In 2021, the suicide rate in India jumped to a record high. According to WHO, India has the 41st highest suicide rate in the world since 2019. The devastating impact of suicides cannot be just reduced to statistics. It affects communities, tears families apart, leaves behind a trail of overwhelming guilt, grief and questions that remain forever unanswered. Rarely a sudden decision, suicide is the result of complex interplay between diverse factors including environmental, social, economic and mental health factors.

Each year, 10 September is observed as the Suicide Prevention Day with an aim to reduce stigma, spread awareness about the issue and globally send across the message that suicides are preventable. Ironically, just days before the Suicide Prevention Day, 21 lives succumbed to suicide in the Edtech city Kota, Rajasthan, this year. It is the fourth incident this month and the highest in eight years. In the face of sobering reality, the Kota administration ordered installation of ‘anti suicide devices’ on the ceiling fans to stop students from committing suicide. If an object weighing more than 20 kilograms will be hung from the fan, the attached spring would expand and simultaneously trigger a siren. This sparked a debate about the effectiveness of this measure as a suicide prevention strategy. Some called it a ‘desperate’ attempt and seemed ‘unsure’ of its effectiveness as a strategy to reduce suicides. Others have gone on to call it a ‘bizarre solution’ to the problem that lacks focus of the underlying causes of suicides.

While tackling the root causes of suicides is imperative, one often overlooked and powerful strategy in suicide prevention is restricting access to methods which is increasingly becoming a part of various national suicide prevention strategies around the world.Access to means, such as medications, firearms, pesticides, and even bridges, plays a vital role in the lethality of suicide attempts. Firearms are a prevalent and lethal method of suicide in several nations. Another common method of suicide is medicine and poisonings. In many of the agrarian societies, pesticide ingestion is a prevalent method of suicide. The impulse to end one’s life can often be fleeting. However, a moment’s access to a lethal method can lead to permanent tragedy. The likelihood of a fatal outcome can considerably increase if individuals have easy access to methods of suicide. The 2003 study by Gunnell and Eddleston is consistent with this broader understanding of high suicide rates. Their key finding was that easy availability of pesticides in developing nations contributed to a higher incidence of suicides by intentional ingestion of pesticides.

On the other hand, individuals in crisis who do not have access to suicide methods have a greater chance of survival. Abu al-Ragheb and Salhab in their 1989 research claimed that a decline was observed in fatal pesticide poisonings in Jordon after decrease in the import of some toxic pesticides and banning of certain other pesticides. A 1994 study by Patrick and colleagues reported a decline in the overall suicide rates in a surrounding area after installation of ‘anti-suicide fences’ along the bridges in Washington DC. In England and Wales, following legislations on car exhaust emissions in 1993, suicides by self-asphyxiations using car exhausts led to overall decline in suicide rates. Switzerland’s efforts to reduce access to firearms have also yielded positive results.

However, it is crucial to note that these restrictive strategies have not been successful in isolation. The success of these measures is greatly influenced by the other methods being employed in conjunction. For instance, in Jordan and Western Samoa, the decline in suicide rates was the result of decreased availability of pesticides as well as increased awareness about the issue. Implementing these strategies in isolation reduces their efficacy and reduces them to a ‘band-aid solution’. Limitation of access to suicide methods as a strategy has also been criticised for the possibility of substitution. Individuals may use an alternate method of suicide if one is restricted. In 2001 study, Amos, Appleby, and Kiernan reported a decline in number of suicides by self-asphyxiation using car exhausts among young males and females but increase in the number of suicides by hanging in the group.

There is a need to adopt a public health approach to suicide prevention which involves employing multiple strategies. Means reduction is a vital but only one of the components of suicide prevention. Media’s portrayal and coverage of suicide incidents can also lead to ‘copycat suicides’ by increasing visibility and access to certain methods. For instance, the premiere of the series ‘13 Reasons Why’ was followed by several reports of surge in teen and adolescent suicide. Although a more recent 2019 study claims that the surge was not statistically significant, the researchers still emphasize the need for the producers of the show to recognize the potential for harm.

There is an increased emphasis on improving risk assessment of suicide to ensure suicide prevention. An area of ongoing research includes risk assessment using genetic screening and computer testing. Healthcare professionals including mental health professionals play a vital role in identifying individuals at risk and training gatekeepers like teachers, community leaders, first responders and people in general to identify the warning signs. Warning signs such as expressing feelings of hopelessness, giving away possessions, being socially isolated, expressing thoughts of suicide can serve as critical cues in assessing immediate risk of suicide. Mental health history of disorders like bipolar disorder, depression and substance abuse are also crucial factors in suicide risk assessment. A history of previous suicide attempts is also a red flag in risk assessment. After identifying individuals at risk, tailored interventions may be provided to suit their specific needs. These may include therapy, crisis hotlines, pharmacological treatments, and hospitalizations. Risk assessment can serve as life saving tools by ensuring that these individuals in crisis receive the timely help that they need.

Additionally, more coordinated social and public health interventions must be implemented to manage suicidal individuals and morbidity associated with suicide. There is a need for collective identification and promotion of protective factors that can mitigate the risk of suicide. School based programs, workplace mental health programs and community-based suicide prevention programs that focus on fostering social connectedness, providing resources, enhancing coping skills and resilience can help in addressing the issue comprehensively and proactively.

In conclusion, suicide prevention is a complex undertaking. In the face of rising suicide cases in Kota, there is a need to find long term solutions to underlying issues of our imperfect education system, toxicity of the coaching centres, parental pressure, fear of failure and poor living conditions. Means reduction is one of the vital aspects of this effort. However, it is crucial to note that it can only be partially successful if implemented singularly. By implementing interventions and policies that aim to reduce access to suicide means like firearms, medicines, pesticides, other lethal methods, and reduced possibility of suicide by hanging, several lives can be saved. Addressing underlying root causes of suicide remains of paramount importance. Though we cannot deny that until long-term solutions are found for those causes, reducing access to suicide methods can serve as a powerful, tangible, and effective measure to reduce tragic loss of lives.

(Dr Shalini Mittal is Assistant Professor of Psychology, School of Liberal Arts, Bennett University)