The Google search identified 475 articles. 256 were excluded- 1 page “could not be found”, 8 reported unclear causes of death or homicides, 27 reported suicides prior to February 2020, 149 reported non-COVID suicides, 25 reported suicidal attempts or ideation, 36 had data from other countries, and 10 were unrelated to suicides. The remaining 219 articles, along with 151 articles from the online database, were included for analysis [Appendix Table1].
COVID-19 related suicides
These 370 articles covered 291 suicides (Appendix Table2, Table1). Information regarding gender and region were available for all, whereas information on age, and the method were available for 247 (84.9%) and 264 (90.7%) respectively. 85.9% of the suicides were by men. 47.1% occurred in persons between 20 and 39 years of age (if one includes the 10 “youth”, this figure is 50.5%). There were eight couples. Hanging was the most common method (63.2%). Two states, Uttar Pradesh and Maharashtra, accounted for the highest number of identified suicides; both States are also among the worst affected by COVID-19 [31]). The number of suicides increased over time, with the highest number and the largest percentage increase recorded in May 2020 (Figure1).
Table 1: Demographic data of identified suicides
Demographic data
|
Categories
|
N
|
%
|
Gender
|
Male
|
250
|
85.9
|
Female
|
40
|
13.7
|
Transgender
|
1
|
0.3
|
Age category
|
10-19
|
15
|
5.2
|
20-29
|
66
|
22.7
|
30-39
|
71
|
24.4
|
40-49
|
43
|
14.8
|
50-59
|
31
|
10.7
|
60 and above
|
21
|
7.2
|
Unspecified
|
44
|
15.1
|
Suicide method
|
Cutting
|
2
|
0.7
|
Drowning
|
14
|
4.8
|
Drug overdose
|
1
|
0.3
|
Electrocution
|
1
|
0.3
|
Firearm
|
1
|
0.3
|
Hanging
|
184
|
63.2
|
Jumping
|
18
|
6.2
|
Pesticide
|
14
|
4.8
|
Poison
|
12
|
4.1
|
Railway
|
6
|
2.1
|
Self-immolation
|
11
|
3.8
|
Unspecified
|
27
|
9.3
|
States/ Union Territories
North India
|
Haryana
|
13
|
4.5
|
Himachal Pradesh
|
2
|
0.7
|
Chandigarh
|
2
|
0.7
|
Punjab
|
17
|
5.8
|
Delhi
|
3
|
1.0
|
South Kashmir
|
1
|
0.3
|
Uttarakhand
|
6
|
2.1
|
Uttar Pradesh
|
46
|
15.8
|
North east India
|
Arunachal Pradesh
|
1
|
0.3
|
Assam
|
2
|
0.7
|
East India
|
Bihar
|
8
|
2.7
|
Jharkhand
|
14
|
4.8
|
Odisha
|
7
|
2.4
|
West Bengal
|
4
|
1.4
|
Central India
|
Chhattisgargh
|
5
|
1.7
|
Madhya Pradesh
|
4
|
1.4
|
West India
|
Gujarat
|
27
|
9.3
|
Rajasthan
|
7
|
2.4
|
Maharashtra
|
39
|
13.4
|
South India
|
Kerala
|
17
|
5.8
|
Karnataka
|
21
|
7.2
|
Andhra Pradesh
|
6
|
2.1
|
Telangana
|
23
|
7.9
|
Tamil Nadu
|
15
|
5.2
|
Puducherry
|
1
|
0.3
|
Pandemic-related stressors
There were 10 pandemic-related stressors in connection to 284 suicides (Figure2). 7 suicides could not be classified.
Disease-related stressors
Fear of the virus: Several persons died by suicide, after fearing the virus. Some had tested positive shortly before, for example, Case 168 who ‘was tense… went into depression’. (The Indian Express, 10.05.2020). Others feared contracting the virus, or perceived they had been infected, despite reassurances or evidences to the contrary. For example, Case 1 ‘started panicking when his cold, cough and fever did not subside even after taking medicines’; his son said, “even the other villagers told him that if he really had coronavirus, the doctors would have quarantined him… (but) my father was worried that the virus would spread to us. He hanged himself to save us” (Hindustan Times, 12.02.2020). Some who underwent testing panicked before receiving their results, for example, Case 2. Others feared for their loved ones; for example, Case 282 ‘set herself ablaze fearing her husband who works abroad was affected with COVID-19’ (Mathrubhumi, 31.05.2020).
Isolation: Many suicides occurred during quarantine or shortly after, in those testing positive or “suspected” of having COVID-19 and/or who had travelled recently. Excerpts indicate that this experience may have cut off sources of support, and led to loneliness and rumination, especially for those worried about the virus or the lockdown. For example, Case 75 who was admitted to an isolation ward hanged himself ‘out of frustration and loneliness’ (Pune Mirror, 11.04.2020); Case 41 who had escaped from a quarantine centre to meet his family had ‘started panicking… despite repeated attempts by officials to make him understand that it was just a precautionary measure’ (Hindustan Times, 02.04.2020); and Case 254 who was quarantined at home had been ‘worried as he had no money left’ (News18, 22.05.2020). Some persons voluntarily secluded themselves to prevent spreading the infection to others, for example Case 112 (OpIndia, 22.04.2020), whereas others were forced into isolation by their families; for example, Case 20 who returned to India from Maldives, ‘had gone into depression after his parents and elder brother refused to let him into the house’ (The Times of India, 28.03.2020).
Discrimination and rejection: Some persons who returned home, or had symptoms were forced by their local community to get tested or pestered to vacate their accommodation. For example, Case 45 ‘killed himself after people in the neighbourhood insisted that he cannot continue to live there since he was a “corona patient"’. [A friend said] “When he kept coughing, the neighbours informed the police who took him to a hospital for testing”. (Livemint, 14.04.2020). Their family members also faced harassment. For example, a relative of Case 63 (who had ‘admitted himself in the hospital as per the wishes of villagers’) said, ‘People were not buying milk from us. It was the only source of income’ (The New Indian Express, 05.04.2020). In another instance, a man who was quarantined after returning to village, and his wife (Cases 103, 104) died by suicide after he ‘had been prevented from going home… although he had no symptoms’ and ‘some villagers had been mounting pressure on __ [wife] to leave the village over suspicions that her husband had contracted the disease’. (The Telegraph, 17.04.2020). Some persons were rejected by their own families. For example, Case 221 who had returned home was ‘kept in a separate room… his wife looked at him through the window, but did not go near… because of fear of Corona… (his) loneliness was irritating him… repeatedly begged his wife to come to him. But she did not listen…. (he) was so hurt that he hanged himself’ (News Nation TV, 15.05.2020). In one instance, Case 208, a medical supervisor, elaborated in his suicide note about how ‘he was harassed and pressurised by the locals asking him not to allow COVID-19 swab test centre’ (Mumbai Mirror, 14.05.2020).
Lockdown-related stressors
Economic hardship: Several individuals experienced economic hardships; these included threats to or loss of livelihood; reduced or no income; difficulty supporting family; going into or difficulty paying off debt; and acute impoverishment. For example, Case 217 ‘slipped into depression’ after his employer ‘refused to help him financially and didn’t even give him salary… had borrowed money to meet the household expenditure during the lockdown and the lenders were asking him to return their money’ (The Tribune, 16.05.2020). A policeman investigating Case 182, reported, “When we visited their tin-shed home, the small room had barely anything. Even the plastic bottles were empty. They had neither food grains nor pulses nor anything else left to eat. They were drinking only water. They were crying because of starvation and asking their elder sister [case] to give them food. The girl's father was a daily-wager. Since the lockdown, he had no work. The neighbours gave them food, but she was ashamed of her plight and was humiliated by the fact that she had to beg every day” (The New Indian Express, 12.05.2020). Problems compounded, and some persons saw no way out. Case 231, for example, wrote, “I continue to suffer without work and do not have money even for food, but my landlord is demanding room rent. He is harassing me every day and I cannot take it anymore” The Logical Indian (20.05.2020).
Desperation to be connected with loved ones or return home: Social distancing measures and travel restrictions separated people from their loved ones. For example, Case 199, a young housemaid, was ‘disheartened that she was unable to go home… her sister had given birth to a child and (she) was apparently upset by her inability to pay a visit’ (Sakshi, 13.05.2020); and Case 72 ‘was missing his wife who had gone to visit her parents, and couldn’t move back’ (Jagran, 09.04.2020). Migrant workers who had lost their livelihood were especially desperate to return to their hometowns. Case 167 ‘had run out of food and money several days before... not once but twice he had managed to book train tickets to his hometown… but both times, it had been cancelled’. His family reported him to be “scared and restless, just wanted to go home… thought he will never be able to go back” and so “depressed” that “he even planned to walk back home”. They said that the “uncertainty killed him” (The Wire, 13.05.2020). Case 128, who walked from Hyderabad, where he worked, to his home in Maharashtra’s Gondia district (650 km away) hung himself on a tree about 160 km from home, as he ‘lost his will to complete the remaining part of the journey’ (The Indian Express, 02.05.2020). Case 152 ‘hurled himself in front of a goods train’ after being ‘overwhelmed with depression after missing the only special train that would have taken him home’ (The Times of India, 09.05.2020).
Craving for alcohol: Liquor stores were shut during the first 40 days, as alcohol was not an ‘essential’ commodity. This resulted in suicides by ‘addicts’ experiencing craving and withdrawal symptoms. For example, Case 39 was ‘visibly depressed’ (Telangana Today, 01.04.2020) and Case 13 ‘had turned violent’ (Asianet News, 27.03.2020). Such suicides were observed mainly in the Southern States [Table 1], which account for over 40% of India’s alcohol consumption.
Domestic disputes: Some had argued with their family shortly before they died. In a few cases, the arguments were related to disobedience of lockdown rules or behavioural changes following the lockdown; for example, Case 136’s was ‘angered’ after his ‘father reprimanded him for repeatedly going to see his girlfriend outside the house’ (Navbharat Times, 02.05.2020), and Case 113’s ‘had started playing PUBG [online game] regularly… [was] furious at being scolded by his family members for playing the game for several hours’ (Hindustan Times, 26.04.2020). Lockdown-induced financial problems also led to quarrels; in one instance involving a married couple (Cases 137 and 138), the policeman said “[Wife] had taken 5 lakhs as loan from a local committee for hiring a truck for their livelihood. She used to repay the instalment to the committee with the income from the truck… (but) the amount of loan accumulated as plying of vehicles was stopped. On the other hand, the lenders started pressurising her for early payment. The non-payment of loan led to dispute between the husband and the wife” (The Times of India, 04.05.2020).
In two particularly disturbing incidents, men murdered their families, and then killed themselves. According to Case 56’s daughter, “They [parents] could not bear being with each other and were frustrated to be together 24 hours. They were having regular quarrels since last ten days and had even started hitting each other. Today, they had been fighting since morning. In the evening, my mother said something and my father rushed to the kitchen in rage. He repeatedly hit her and she died” (The Week, 03.04.2020). Case 239 ‘murdered his three children and hanged himself… (was) already at home, couldn’t land employment… [and] had been fighting frequently with __ [wife]… after she chided him for not looking hard enough for a job’ (The Times of India, 19.05.2020).
Aspirational disappointments: For some people, the lockdown meant a delay or a failure in achieving major aspirations related to relationships or work, and the loss of their life’s dreams and efforts. For example, teenagers Cases 67 and 68, ‘took the step as their families didn't approve of their relationship and they couldn’t flee home due to the lockdown’ (Outlook, 07.04.2020); Case 124 ‘was depressed over the uncertainty about her foreign study plans due to the lockdown’ (The Times of India, 01.05.2020); and Case 266 (an actress) ‘wrote in a suicide note that she couldn’t live with “broken dreams”’ (Hindustan Times, 27.05.2020). Six persons committed suicide following postponement of their engagement or wedding. Case 178 for example was ‘quite upset’ when the nationwide lockdown was first implemented, as ‘after a very long search for a suitable life partner, [she] was finally going to get engaged’. When the lockdown continued, she ‘could not handle it anymore’ (Ahmedabad Mirror, 13.05.2020).
Restrictions to behaviour: Staying indoors, and the resulting behavioural restrictions triggered some suicides. For example, Case 268 ‘wasn't allowed to step outside the house… used to go cycling and playing in the park every evening…. before killing himself, he had spoken to a friend on WhatsApp about being bored’ (Mumbai Mirror, 29.05.2020); and Case 263 ‘had been suffering from depression ever since he was unable to go for a morning walk’ (The Times of India, 24.05.2020).
Police violence and harassment: Some persons who had broken quarantine or lockdown rules were harassed or beaten by police officials, and were upset and humiliated. For example, Case 44, who had left the quarantine centre to help his sister-in-law said that a ‘constable beat me up severely’. In an audio clip he released to the public, he talked about his trousers being ‘stained in blood’ and said ‘I don’t want to live now. Because of him [constable], I am killing myself’. His brother confirmed this, and also said that the Police had ‘shot a video of the incident to shame him’ (The Wire, 13.04.2020). Similarly, Case 60 who had travelled to his native district on a bicycle, was ‘arrested’ by the Police, ‘they released him…. (but the) vehicle remained in police custody’. He made a video in which he says, ‘(The) Police… are responsible for my death’ (Newsd, 03.04.2020).
Vulnerable groups
These included:
Demographic populations: In general, young people were affected [Table1]. Notably, all aspirational disappointments were only seen in persons 30 years or younger. Case 166, for example, ‘had been disturbed over the delay in his exams… was insecure that he might not get employed… wanted to give her (mother) his first salary’ (Mirror Now Digital, 12.05.2020). Men were particularly hit by economic downturns, especially if they were the breadwinners for large families, and caring for dependents. For example, Case 141 was neither ‘able to buy medicines for his bedridden father suffering from paralysis’ nor ‘able to pay his younger brother’s tuition fee’ (Odisha Bytes, 06.05.2020) and Case 82 ‘was under tremendous pressure to manage his family of nine members after losing his only source of livelihood’ (NewsClick, 13.04.2020).
Socially disadvantaged groups: Those already poor, or in debt were affected by the lockdown. Case 281, a ‘sacked hotel clerk’ left behind a suicide note that said, ‘I am committing suicide because of poverty and unemployment’ (The Telegraph, 31.05.2020), and Case 180, an employee in a milk dairy, who was ‘under pressure from private financier’ said, “I am being threatened that if I don't pay money in two days then they will kill me” (The Times of India, 12.05.2020). Daily wage labourers, those who owned or operated small business, and persons employed in non-essential businesses were also affected. For example, Case 171, an auto rickshaw driver committed suicide ‘when he realised he wouldn’t be able to pay instalments of the loan he had taken to buy an auto…. the vehicle has been lying idle since the lockdown started’ (Mumbai Mirror, 15.05.2020); and Case 115, who worked as a gardener for a private hotel ‘was told his services were not needed’ (The Telegraph, 23.04.2020). Farmers were another group. For example, Case 197 ‘suffered loss’ as ‘he was unable to sell cucumbers he had grown on rented land’ (Deccan Herald, 15.05.2020). Migrant workers experienced multiple stressors. Case 84, for example, was ‘upset as he could not go home’ and ‘had no money to pay the room rent’ (Northeast Now, 14.04.2020) and Case 245 who had returned to Bihar from Delhi ‘was frustrated after being put in quarantine for the second time as he was sent to a quarantine centre in Delhi as well’ (The New Indian Express (21.05.2020).
Some persons had had recent losses or ongoing interpersonal stressors. For example, Case 256’s father ‘died due to lack of treatment’ during the lockdown (Satya Hindi, 23.05.2020), and Case 122’s husband and in-laws ‘were reportedly harassing her family to fulfil their dowry demands’ (The New Indian Express, 30.04.2020). Some persons had no family, were separated from their spouses, or living alone. For example, Case 12 who believed he was infected was ‘separated’ from his wife (The Federal, 27.03.2020); and Case 291’s ‘parents had died long ago and he was living alone and had no money to buy ration (food)’ (Deccan Chronicle, 28.05.2020).
Persons with health problems or risks: Persons testing positive, showing flu symptoms and/or awaiting test results, or those having ill friends or relatives were vulnerable to fear. For example, Case 134 who had ‘fever and difficulty in breathing’, ‘was under acute depression as he feared having contracted the deadly COVID-19’ (The New Indian Express, 03.05.2020), and Case 146 was in ‘a state of panic following detection of coronavirus cases in the village’ (Newsd, 07.05.2020). Some persons were from COVID-19 ‘hotspots’, for example, Case 83 from Uttar Pradesh; Case 98 from Mumbai; and Cases 272 and 273, from Tamil Nadu. Four persons had been involved in COVID-19 management efforts, and their suicides were connected to stressors related to these efforts. For example, Case 51, a disaster management officer had been ‘afraid that she could infect her son’ (Hindustan Times, 05.04.2020), and Case 133, a medical student ‘was attending to coronavirus patients and had told her parents that she was under tremendous stress’ (India Today, 01.05.2020).
Some persons had chronic physical ailments. For example, Case 121 had kidney problems (Mangalorean, 27.04.2020), Case 183 had lung cancer (ThePrint, 13.05.2020), Case 117 ‘was in excruciating pain’- this was ‘compounded by the unavailability of alcohol’ (Mumbai Mirror, 26.04.2020), and Case 179 was HIV-positive, and committed suicide ‘due to the loss of livelihood and unavailability of medicine’ (Outlook, 12.05.2020). Others had mental health problems. For example, Cases 53 and 205 had been ‘mentally ill’ and undergoing treatment for several years (LiveHindustan, 04.02.2020, Outlook, 14.05.2020), and the two unemployed actors (Cases 216 and 266) were reportedly suffering from ‘depression’. In others, the pandemic resulted in mental health problems; for example, Case 189 had ‘got addicted to alcohol after his work stopped’ and ‘had consumed alcohol before committing suicide’ (Telangana Today, 13.05.2020) and Case 118 was ‘under depression due to the present lockdown’ (India TV, 25.04.2020).