The Hindu : When hope finally dies...

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Sunday, Jun 02, 2002

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When hope finally dies...

They are all people who believe they have reached the end of the road. That there is no way forward, no way out and no one around who cares. Anjali Mody on what drives people to suicide.

FIRST THERE are the exam results. Then there are the suicides. This has been a pattern in May, every year for the last many years. Leaving families baffled and people asking: what makes a 16-year-old kill herself? After all, when poor farmers in Andhra Pradesh chose to die after their cotton crop failed, there was apparently an `explanation' — they faced financial ruin, abject poverty, and an insurmountable debt burden. But, for a 16-year-old with her entire life ahead of her, could just one exam result make it all so impossibly pointless?

Psychiatrists say that while they do not have all the answers there is a thread that connects the 16-year-old who felt life was not worth living after failing an exam, the farmer in Andhra Pradesh left with no means to feed his family and the gossip column celebrities from prominent families who have chosen to end their lives.

They are all people who believe they have reached the end of the road. That there is no way forward, no way out and no one around who cares. Over 100,000 commit suicide in India each year, according to the police's crime records bureau.

Medical professionals say these are only figures of the cases which are reported, many are simply passed off as accidents.

Suicide is the end of a very lonely road. One littered with attempts to find diversions, look for help. Doctors describe suicide and attempted suicide (of which there are ten times as many cases) as a cry for help.

Most of those who take that final step will, say psychiatrists, have tried to communicate their sense of hopelessness and helplessness to people around them, but will have either not been heard or will have sent confusing messages that are not taken seriously by those around them. "Life is not worth living" statements are easily ignored as `filmy' histrionics.

Declarations of a desire to die may be written off as acts of attention-seeking emotional manipulation. But, in far too many cases attention is just what is needed.

Says Avdhesh Sharma, a New Delhi-based psychiatrist, "there should be no need for suicide. There are very few situations so extreme that they have no solution. It is just that the person involved cannot see it."

Why? Because a person who contemplates suicide is depressed — is in "an identifiable state of abnormality". The power to reason, the ability to think clearly in such circumstances are not perfect. A person may feel he has no means of coping with his situation, be unable to see solutions to the problem, or a different way of dealing with it and need someone to point it out to him. But, that someone would have to first deal with the fact of depression, which defines a person's mental state.

Depression is a necessary condition for suicide. Even a person who has no history of mental illness will be clinically depressed when attempting suicide. The trouble is that symptoms of abnormality discernible to a mental health professional may not be so clearly apparent to those around the person, including the family doctor.

Abnormal behaviour — moodiness, loss of sleep and appetite, sullenness or silence could all be explained away as "appropriate" to the situation the person is in and the stress he is under — which could be due to any number of reasons, for instance bereavement, financial difficulties or illness.

Dr. Sharma says a major problem is that in most families no one is willing to sit down and talk about a problem. So they have in fact no way of knowing how enormous it is. A depressed person's ability to cope with a situation depends on his/her own ability to do so, but also on the support that they receive from the people — family and friends — around them.

Unfortunately, even in families that are apparently close-knit and caring there is a tendency to avoid the issue. This reflects a larger social attitude to mental illness: it is a subject that is not acknowledged, rarely discussed, secreted away, and hopefully forgotten while `normal' life carries on.

The importance of a listening ear to someone contemplating suicide is something that can be provided by a suicide helpline such as Sneha in Chennai, which receives a call every 20-25 minutes, and Sanjeevani in New Delhi, which offers extended psychological counselling to the tens of people who call or come looking for help.

The tragic fact is that in far too many cases suicide is the end not of a short and uncharacteristic period of depression, which may be misunderstood or misinterpreted, but of a very long period of untreated mental illness. An illness left untreated by individuals and families who do not want to be burdened with the `stigma' of mental disease. They would rather live a lie, create a fiction, to conceal the fact that one of their family may have a problem rather than get medical attention. A man who does not go out to work "runs a business from home" or is "still completing a course". Someone may be described as moody or hot-headed when in fact that someone's fluctuating behaviour is a sign of chronic mental distress.

Years of living a lie can and often does end in suicide. More often than not, a suicide is simply not acknowledged as such, by the family, the medical practitioner certifying the death and the police (for a small consideration, naturally).

The cover-up continues, because "an admission of suicide is an admission of mental illness," says Amiya Banerji, a psychiatrist at New Delhi's VIMHANS hospital. And so the cycle of disease, deceit and death continues. Those like the doctors who certify accidental death instead of suicide, apparently to protect the bereaved family from having to deal with an insensitive law which criminalises the act, are feeding prejudices and ignorance about a form of ill-health of which suicide is only the most extreme form.

Attitudes to mental disease are curiously unscientific. Mental disease, unlike other debilitating physical illnesses, is seen as the sufferer's fault in cases where there is a mild dysfunction and largely as genetic, in cases of psychotic dysfunction.

Mental disease is widespread, according to Dr. Banerji, `normal' does not fit most families anywhere in the world; no society is without it, nor are most families.

A family member with a mild form of depression is an inescapable reality at some point or other for most average sized families. Extreme and crippling mental disease affects as many as three in a hundred people.

Yet, for the most part mental disease still remains a taboo subject. Because, according to Dr. Banerji, "people don't want to jeopardise their evolutionary prospects". Meaning what? Marriage and procreation. Even the hint of mental illness in a family apparently has a ripple effect on important things such as the matrimonial chances of the extended family — brothers, sisters, cousins, second cousins. As the popular view is that large numbers of mental disorders are genetic; even the propensity to commit suicide is considered coded into the double helix, when the fact is that only 6-7 per cent of people who commit suicide may have a genetic propensity for it.

The numbers of those who need medical attention for mental illnesses are growing not reducing. Environment and not genetics seems to be the reason.

Anindita Paul, head of Sanjeevani's Crisis Intervention Centre, says changes in society — growing urbanisation and the changes in lifestyle and work culture which demands success defined in rather narrow terms; the breakdown of the traditional family system which has taken away a support structure — have combined to create an environment in which those suffering from mental distress feel isolated, that they have no one to turn to.

According to Dr. Sharma, in the next 10 years mental illness will be the second biggest case of ill-health after heart disease. Yet, those who nominally acknowledge a problem may consult a priest or an exorcist but will not as easily see a psychiatrist, psychotherapist or even a psychological counsellor.

The stigma that attaches to the disease also appears to attach to the doctor who deals with it. No wonder then that there is such a minuscule number of mental health professionals in India — just three psychiatrists per a million people.

There are fewer than 300 seats for post-graduate specialisation in psychiatry in the country.

A large number of those who qualify go abroad. There are, in fact, fewer psychiatrists in India than psychiatrists of Indian origin in the United States. One World Health Organisation study places the figure of psychiatrists in India at 3,500. Never mind psychiatrists, even psychotherapists and counsellors, despite the large number of psychology courses offered at Indian universities, are a rarity outside the big cities. Where they are available they have few takers.

The state's attitude to mental health also reflects society's unwillingness to face the issue head on. The Indian Mental Health Act (1987), deals only with the institutions that offer residential care for the mentally ill. It sets out the procedures for commitment in custodial care but does little for the vast majority who are not in the "severely psychotic" category. While the Act requires all States to provide mental healthcare down to the district level, only two States — Karnataka (where the National Institute for Mental Health and Neurosciences based in Bangalore has played a major role) and Tamil Nadu (after the Erwadi asylum fire) — have done so.

Until attitudes to mental health change, those who suffer and in their suffering feel completely discarded by society will continue to take the lonely route to self-inflicted death.

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