India has data on suicide. It has data on mental illness. But among people living with severe mental illnesses such as schizophrenia, bipolar disorder and major depression, there is a worrying gap, leaving these vulnerable groups at the receiving end.
A recent article published in the Indian Journal of Psychiatry has flagged the lack of systematic Indian data on deaths by suicide among people with severe mental illness (SMI), warning that this information gap could weaken suicide-prevention efforts among these groups of people.
The authors—Dr Vikas Menon, Dr Sujit Sarkel and Dr Chittaranjan Andrade—pointed out that suicide is a major public-health concern globally, with more than 700,000 deaths reported every year. In India, more than 170,000 suicide deaths were recorded in 2023, as per various data.
Dr Menon and Dr Sarkel are from the Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, while Dr Andrade is from the National Institute of Mental Health and Neurosciences (NIMHANS).
They pointed out that the burden may be considerably larger when attempts are included and given that many remain unreported. For every suicide death in India, there are estimated to be more than 15 attempts, according to the National Mental Health Survey data as cited by the authors.
Yet, they argued that India still does not have adequate information on who among people with severe mental illness is most at risk, when the risk is highest and what factors may protect them.
Mental illness is strongly associated with suicidal behaviour, said the psychiatrists, citing a global meta-analysis that found that people with mental illness had a 16-fold higher risk of suicide than healthy individuals.
Suicide rates have traditionally been reported at between 5% and 14% among people with schizophrenia and around 15-20% among those with bipolar disorder and major depressive disorder.
But the authors caution that these figures have been questioned because of problems such as small samples, selection bias and inadequate follow-up.
More importantly, much of the evidence comes from Western countries, noted the authors.
“There is a striking paucity of Indian data on deaths by suicide in SMI,” Dr Menon emphasised, noting that the only significant long-term Indian evidence on suicide in schizophrenia comes from the Madras longitudinal study, which began in the early 1980s.
There are no comparable long-term studies on suicide deaths among Indians with bipolar disorder or major depressive disorder; they point out, Dr Menon said, observing that India may not necessarily mirror the West.
Family structures, social support and community networks can influence the risk of suicide. Despite the gradual shift from joint to nuclear families, strong family connections continue to play an important role in India.
For a person living with severe mental illness, this support can mean help with medication, hospital visits, daily activities, finances and emotional wellbeing.
“Living with family or having social support, and receiving adequate treatment with good adherence were found to be protective” against suicide in schizophrenia, the authors noted, citing earlier research.
India’s community-based mental healthcare system may also provide an additional layer of support through health workers and district mental-health programmes.
But this protective cushion cannot be assumed to remain unchanged.
Urbanisation, migration, smaller families, social isolation and rising pressures of modern life could alter the risk profile, warned the authors as they recommended that “these changes need to be studied rather than presumed to be harmless.”
A diagnosis alone cannot identify who is most vulnerable.
Previous research has linked suicide in schizophrenia to factors such as command hallucinations, hopelessness, social isolation, family stress, hospitalisation and other medical conditions.
In bipolar disorder, factors including being male, living alone, psychiatric comorbidity and previous hospitalisation have been associated with higher risk.
Depression too has a combination of demographic and clinical risk factors.
“This means that simply knowing that a patient has schizophrenia, bipolar disorder or depression is not enough. Doctors need to understand which patients are at greater risk and at what stage of illness that risk rises,” said the authors.
That information could help healthcare systems direct limited resources towards people who need closer monitoring and support, the authors said, stressing that families can be part of the safety net.
The Indian context makes family involvement particularly important.
The authors also noted that families often provide sustained support to people with severe mental illness — from ensuring treatment adherence to providing emotional and financial assistance.
But families themselves need support and awareness.
A carer who recognises worsening depression, withdrawal, hopelessness, unusual behaviour or other warning signs may be able to seek help before a crisis develops.
This is particularly important in areas where specialist mental health services remain difficult to access.
The authors thus propose building a more reliable system to track suicide deaths among people with severe mental illness.
“One approach would be to create multicentre hospital registries and link them, where possible, with civil death-registration systems, police records and forensic data.”
Such systems could initially begin in selected institutions and eventually develop into a national surveillance network, said Dr Menon.
The authors also suggested verbal-autopsy studies to identify deaths that occur outside the healthcare system.
District mental health programmes could help improve community-level reporting by using their existing network of health workers.
Another option would be to follow large groups of patients with severe mental illness over several years and examine which clinical, social and demographic factors are associated with suicide.
“The objective is not simply to produce another set of statistics. Reliable Indian data could answer practical questions: Are suicide risks different between rural and urban patients? Does strong family support reduce risk? Which stages of illness are most dangerous? How important are treatment interruptions, hospitalisation, social isolation or unemployment?”
The answers could help doctors identify high-risk patients earlier and help policymakers decide where suicide-prevention resources are most urgently needed.
As the authors emphasised, Indian suicide patterns among people with severe mental illness may differ from those seen in Western countries. But without systematic research, that remains an assumption, concluded the study.
