Mental health is defined by the World Health Organization (WHO) as not the mere absence of a mental health condition, but a state of well-being that allows individu-als to realize their full potential, demonstrate resilience in the face of adversity, be productive, make meaningful relationships, and contribute to their communities (World Health Organization, 2004). Of note, a component of mental health promo-tion is implicit in this definition. The huge burden of mental health issues on the individual, family, and the society necessitates steps to prevent mental health issues and promote positive mental health using approaches that are rooted in a public health framework. Public mental health, therefore, comprises of population-level approaches to mental health, encompassing treatment, prevention, and promotion of mental health in the community.
Recent data from the Global Burden of Disease (GBD) study 2019 show a sig-nificant rise in proportion of disability-adjusted life-years (DALY) due to mental health disorders from 3.1% in 1990 to 4.9% in 2019. During this period, mental disorders rose from the 13th leading cause of DALYs lost worldwide to seventh leading cause of DALYs lost. Of these, depressive and anxiety disorders were the leading contributors to disease burden (GBD 2019 Mental Disorders Collaborators, 2022). This is important because apart from compromising mental health, they increase the risk of outcomes such as suicide and self-harm.
Concurrent with these developments, annual global deaths by suicide have increased by 6.7% over the last three decades (1990–2016), culminating in over 8 lakh people taking their own life in 2016 worldwide, albeit with regional variations in suicide burden (Naghavi, 2019). Suicide and self-harm, which in GBD 2019 was ranked at 18 among the leading causes of global mortality, can increase the negative impact of mental disorders on population health. In recognition of their detrimental impact on public health, suicide is identified as a key public health issue in the Comprehensive Mental Health Action Plan by the World Health Organization. Further, suicide-related mortality is an indicator (section 3.4.2) under target 3.4 of the Sustainable Development Goals 2030, which target a one-third global reduction in premature mortality due to noncommunicable diseases through treatment and promotion of mental health (World Health Organization, 2018). Adding to the complexity are suicide burden in specific subpopulations such as elderly, adolescents, and marginalized groups (e.g., ethnic and sexual minorities). Finally, over the last five decades, there have been signs of a regional shift in the global hotbed of suicide from Western Europe to Eastern Europe to Asia; currently, half of global suicides occur in India and China with suicide rates in South Korea being the highest among developed nations.
Epidemiology of Suicide in South Asia
South Asia represents a suicide- dense region of the world with higher average sui-cide rates compared to global rates. This region comprises the following nations: India, Pakistan, Bangladesh, Afghanistan, Bhutan, Maldives, Nepal, and Sri Lanka. Most of these nations are low- and middle-income countries with inefficient civil registration systems and dearth of reliable suicide data. A review in 2014 estimated that the average suicide rate across South Asian nations with national suicide data was 25.2 per 100,000 population; this figure is 2.5 times the global average rate of 10.5 per 100,000 population in 2019 (Jordans et al., 2014).
Another important finding is that the well-known gender paradox in suicide (more males die by suicide than females) is less pronounced in this region of the world; indeed, there is evidence from Bangladesh (Mashreky et al., 2013) for higher female than male suicide rates.
Young, reproductive age women appear to be at the highest risk of suicide among females in South Asia. In fact, this is the only female age strata which equals or exceeds rates in males. Further, suicide is the leading cause of death in the 15–29- year age group in many countries in South Asia while globally it ranks fourth after road traffic accidents, tuberculosis, and interpersonal violence (World Health Organization, 2019). The rates in this age cohort range from 3.4 per 100,000 in Bhutan to 15.7 per 100,000 in India. It has been suggested that higher educational attainment may render greater risk of suicide due to mismatch between achievements and expectations, and public shame (Pompili et al., 2013). However, findings from the latest National Crime Records Bureau (NCRB) data from India suggest that those educated till high school contributed the largest percentage share of total suicides (24%) (National Crime Records Bureau, 2021). Though few countries provide disaggregated data for suicide methods, hanging followed by poisoning are the two favored modes of sui-cide. A steady decline in suicide by poisoning has been noted over the last two decades in many South Asian countries though in Sri Lanka, suicides by poisoning outnumbered deaths by hanging (Arafat et al., 2021).
No reliable national data for suicide attempts/ideation are available in South Asia. A recent meta-analysis focused on women and girls of any age in the eight South Asian countries. Authors estimated a pooled prevalence rate of 5% for suicide attempt. The corresponding figure for suicide ideation was 17%, while among uni-versity students, the figure was even higher (22%) (Mazumder et al., 2022).
Determinants of Suicide and Mental Health
Suicide is best understood as a phenomenon with complex, interacting biopsycho-social and individual-level determinants. Key sociodemographic determinants of suicide include age, gender, ethnicity, marital status, domicile (rural/urban), employ-ment status, and poverty. In general, suicide rates are higher among older adults and males though the gender gap is less pronounced and nearly equal in Asian settings. Rural–urban inequities in suicide rates, specifically higher rural suicide rates, have been consistently reported from both Western and Asian settings. Intriguingly, being married is not necessarily a protective factor against suicide in Asia as much as it is elsewhere (Chen et al., 2012). Other important social determinants of suicide, par-ticularly in Southeast Asia, are stressful life events, interpersonal conflicts, and indebtedness (Arafat et al., 2022). Apart from these, macroeconomic factors such as decrease in gross domestic product and rising unemployment negatively impact sui-cide rates.
On a similar note, unemployment, poor working conditions, low income, and financial strife have been linked to poor mental health. Further, it has been sug-gested the moderating effect of unemployment on mental health may be gendered with a greater effect in men than women. Other determinants of mental health include societal stigma and discrimination, perceived social support, quality of familial relationships, a sense of community belonging, and safety and quality of living conditions. Finally, a host of static social determinants such as nationality and migration status, ethnic minority status, gender, and sexual orientation have also been linked to mental health. A caveat here is that the relationship between mental health and social determinants is bidirectional: poor mental health can lead to poor personal decisions and negatively impact living conditions and familial relation-ships while the stress of poor working and living conditions can take a toll on one’s mental health (Alegría et al., 2018).