Have suicides increased during Nepal lockdown?

One of the stories that has been making the rounds since the Covid-19 lockdown that began nearly six months ago is that the suicide rate in Nepal has gone up in that period. But has it?

Most media coverage tries to draw a correlation and causality between the lockdown, mental health and suicides, and use that to prove government inaction and incompetence on the issue.

Statistics about the number of suicides vary greatly depending on who is doing the counting. Even though the South Asian region does seem to have a relatively high suicide rate, the quality of data is so uneven that it may be too soon to claim that the lockdown has caused an increase.

In June and July, there were a slew of articles stating that there has been a 25% increase in the number of suicides in Nepal after the lockdown began. Similar numbers were picked up by other media, and was repeated so often that it has come to be accepted as the truth, stirring conversation among the youth about support and access to mental health.

However, such analysis comes with its shortcomings due to rudimentary analysis of the limited data that exists in the country. In fact, the authors of various reports themselves acknowledge several limitations on the availability of time-series data to make accurate comparisons with previous years.

However, that does not deter the media from using sensational titles to stories that often read, ‘Lockdown Leads To Increase in Suicides in the Country’. An overview of recent articles on the topic shows that they actually cite the same data source to reach opposite conclusions.

While most media are reporting an increase in the number of suicides, another article concluded Nepal's suicide rate actually went down by 35% in 2019 compared to 2018. To find out the truth, we reviewed dozens of academic papers, journals, newspaper articles, and police records, but it was not easy to draw a credible conclusion.

A literature review of some of the research from the past decades suggests that the suicide rate (per 100,000 people) in Nepal swings widely from 3.7 to 24.9, depending on who is counting. (see table below).

Literature review on the suicide rates in Nepal suggesting various suicide rates per 100,000 people based on various research types and methodologies.

The World Health Organisation (WHO) database suggests that the suicide rate in Nepal is actually in a decline. Although the WHO does not have the latest lockdown figures, it reports an 8% suicide rate in 2016, which in fact is half the number shown by the data from the Nepal Police.

This is puzzling, given that the standard narrative has been that the police are often under-reporting suicide data because its monitoring and tabulation mechanisms are not robust. On the other hand, the WHO data relies on estimates compared to direct reporting from Nepal Police and should have taken into account the under-estimation argument. 

Estimates of suicide rate in Nepal by the World Health Organisations (WHO), crude (2000 - 2016) available here.

Most media coverage of suicides in Nepal rely on Nepal Police data (graph below), but even here the numbers have not been recorded for long enough to draw a definitive conclusion on trends during the lockdown. Only in the past three years has the Nepal Police started collecting reliable and detailed data, but even within that, the frameworks for data collection are different.

Before 2018-19 only annual data was available to researchers. Since then, the raw data captures gender and monthly suicide trends, which provides a better proxy for comparison. It would be imperative to continue this data disaggregation before jumping to conclusions about annual trends, or correlating suicide rates to the Covid-19

A comparison of monthly suicide data for 2019 (blue) and 2020 (red) as recorded by Nepal Police. The last two Nepali months in the graph are April-May and May-June 2020.

There has reportedly been increased attention to mental health services in Nepal in recent years, and a dedicated hotline for suicide prevention. While this is true, it is still difficult to conclude a causality in either direction given the significant data limitations about mental health and suicide prevention and societal taboos.

Moreover, various researchers have relied on different methodologies, including surveys and estimations, as age-standardised or age-representative groups. Because of these uncertainties, one thing is clear: narratives on the issue should try to go beyond merely pinpointing the rise and fall in the numbers of suicides in the country.

The bottom line is that suicides should not and cannot be taken as a proxy for mental health issues people were experiencing before, during, and will continue to go through even after the lockdown.

To do so, we need better indicators to evaluate mental health impact through all age groups and socioeconomic strata, which requires a systematic shift on how mental health is looked at in the country from an educational, societal, and institutional level.

There have been some promising steps. In 2018, a pilot study of the National Mental Health Survey among 1,647 participants was conducted by Nepal Health Research Council. It highlights the prevalence of any form of mental disorders at 12.9%, while the major depressive disorder at 0.7% for adolescents and 3.4% for participants above 17 years. Current suicidality among adolescents was 8.7% and 10.9% among adults. These numbers are high. While national level scientific studies are in progress to better diagnose the crisis, it is time to start addressing these numbers as well. 

The rise and fall of suicide rates does not matter if nothing is being done to address the underlying causes of the crisis. On Suicide Prevention Day on Thursday 10 September there should be a call to action for parents, teachers, governments, to acknowledge the severity of the mental health crises we have been facing even before the pandemic.

Dr Rastriyata Bhandari is a medical professional based in Kathmandu. Niraj Pudasaini helped with data collection for this article, and is a student at New York University Abu Dhabi.  

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