Imitative Suicide, Mental Health, and Related Sobriquets

Epidemiology of Suicide in India

Suicide is one of the most common causes of death in young adults, across the world. Despite widespread public health efforts addressing suicide, incidence and prevalence rates appear to be on the rise.¹ In India, in 2016, the age-standardized suicide rate was 14.7 per 100,000 women and 21.2 per 100,000 men.² Suicide rates in the country appear to have fallen slightly, before the novel coronavirus (COVID-19) pandemic, after a worrying rise between 2006 and 2015.^{1, 2} Despite this, India and China contribute to 40% of the 800,000 deaths due to suicide in across the world, every year.¹ Data on the incidence of imitative suicide in India is lacking. The Global Burden of Disease (GBD) Survey indicated that suicide was the leading cause of death in India in 2016 among those aged 15–39 years, the age group most vulnerable to the imitative effect. In total, 71.2% of the deaths by suicide among women and 57.7% among men were in this age group.²

Suicide and Mental Health in the Context of COVID-19 in India

The novel coronavirus infection and subsequent lockdown seem to have further increased the mental health burden and risk of suicides.^{3, 4} News reports indicate an increase in suicide rates in India, though formal statistical reports are awaited.⁵ A survey by The Mavericks India indicates that 61% of the respondents suffered from mental health concerns during the lockdown.⁶ The Jindal School of Law reported that suicide was the leading cause of all nonvirus deaths reported between March 26 and June 11, 2020.⁷

Research from West Bengal during the lockdown indicated that 71.8% of respondents reported feeling more worried than usual, and 24.7% reported a worsening of depressive symptoms in the past two weeks. Strikingly, more respondents (69.6%) were worried about financial losses they were incurring due to the lockdown than about the risk of contracting COVID-19 (52.1%). In total, 34.7% of the respondents reported feeling more anxious, and 24.6% reported feeling more depressed, after reading news coverage of the pandemic.⁸

A similar study conducted in Tamil Nadu reported that 23% of respondents were more stressed than usual due to COVID-19, and 8.01% avoided news coverage because this worsened their stress.⁹

Community centers and nongovernmental organizations (NGOs) have reported a ten-fold increase in domestic violence, including child and elder abuse, in India, during the lockdown. More women filed domestic violence complaints during the lockdown than during a similar period in the preceding ten years.¹⁰ Helplines catering to older adults have also reported a ten-fold increase in calls reporting elder abuse. This is likely to worsen the mental health burden and risk of suicide in the country.

Imitative Suicide After the Death of a Celebrity

The unfortunate spike in suicides after a celebrity dies of suicide (amid widespread media coverage) is a well-known and recognized entity. This resurfaced with renewed seriousness after the death by suicide of a well-known and promising young Indian actor, Mr Sushant Singh Rajput, on June 14, 2020. Although the phenomenon of imitative suicides has been seen over the years, it has become much more relevant in recent years due to the erosion of boundaries through social media, over the top (OTT) streaming platforms, and unfiltered dissemination of information (and speculation). In Kolkata, on 17th June, seven people ended their life by hanging. The methods used and the circumstances of the deaths appeared disturbingly similar to those reported by the media in the death by suicide of Mr Rajput.¹¹ At least one other person attempted death by similar means but was rescued.¹² The deceased persons hailed from different strata and ranged in age from 10 years to 70 years. At least one, the youngest, was a fan of Mr Rajput and was clearly upset by his death and the aftermath, in the days before his own demise. A senior police officer noted that there was nothing connecting these demises expect that they were all fighting uncertainty and helplessness during the lockdown. It is worth noting that these deaths occurred against an established background of the rising incidence of suicide in the city of Kolkata during the COVID-19 pandemic and related lockdown.¹³ Kolkata has seen a 100% rise since March 2020 as per data from the police, with a three-fold rise in June 2020.¹⁴ Similar news reports of suicide by hanging in adolescents were available from the cities of Meerut and Bareilly in Uttar Pradesh, and Port Blair in the Andaman and Nicobar Islands, on 22nd June, all of whom were reported to be fans of Mr Rajput and distressed similarly by his death, personal circumstances and other stressors notwithstanding.¹⁵ All three adolescents had also mentioned the actor in the days before their death to their families and had followed the news coverage of judicial investigations and associated speculation closely.¹⁵ Much of the information on imitative suicide in the aftermath of Mr Rajput’s death is based upon news and reports from the National Crime Records Bureau of India (NCRB); scientific literature on the same is awaited.¹⁴ However, an editorial in the Indian Journal of Psychiatry has noted a rise in imitative suicide and in distress calls, reporting suicidal ideation, to helplines and mental health professionals, in the aftermath of the actor’s death, prompting the Indian Psychiatric Society (IPS) to write to the Press Council of India (PCI) on the same.¹⁶

We postulate than an interaction between the COVID-19 pandemic (and associated stressors, including unemployment in the context of a financial slowdown) and the imitative effect seen in the aftermath of a celebrity suicide is likely to impact the already considerable suicide rate and mental health burden in India. We further postulate that media coverage of the event and its aftermath is likely to play a role in the impact of a celebrity suicide upon mental health, especially among young adults, during the COVID-19 pandemic. In the context of these postulates, a discussion of the Werther and Papageno effects may be relevant.

The Werther Effect

Recognition of the Werther Effect began in 1774 when Johann Wolfgang von Goethe published his novel The Sorrows of Young Werther. The novel was based on a semiautobiographical story of unrequited love wherein Werther, a young artist, falls in love with Charlotte. She, however, is engaged to and subsequently marries Albert. Werther eventually shoots himself—ironically, with Albert’s pistol. The novel is epistolary (i.e., written in the form of letters) and carries a vivid description of dialogues between the three central characters before the suicide happens. The novel became a classic in European literature but triggered one of the first widely known instances of imitative suicides across the world. Many young men recreated the climactic scene from the novel at their suicide, dying with a copy of the book placed nearby.¹⁷

Subsequent Imitative Suicides

Subsequently, on several occasions in the context of a sensationalized news coverage of celebrity suicides, the frequency of reporting of imitative suicides had undergone a transient increase. In 1962, after Marilyn Monroe died of an overdose of barbiturates, the “Marilyn Monroe Group” was constituted to support women from a hospital ward who were devastated by her loss. Three members of this group went on to attempt suicide—one of them with high lethality. The therapist and the supervisor hypothesized that such a group acted as a suicide cluster with a form of behavioral contagion.¹⁸

Similarly, a 10% increase in death by suicide was reported by the Center for Disease Control (CDC) after the death of Mr Robin Williams in 2014. The spike was most notable in middle-aged men, a demographic that identified with Mr Williams.¹⁹

Relationship of the Werther Effect to Media Coverage

Wasserman described a rise in the number of suicides in the United States of America (USA) after stories on suicide were published in the New York Times.¹⁷ Stack noted that the greater the number of inches in a newspaper column dedicated to suicide, the greater the imitation effect.²⁰

Jang et al. noted an increase in the clustering of suicides in the aftermath of seven celebrity suicides between 2005 and 2008.²¹ A similar clustering of suicides was noted around the Golden Gate Bridge between 1999 and 2009 and Foxconn in China in 2010.^{22, 23}

Fahey et al. noted an increase in emotional responses on Twitter, between 2010 and 2014, around the suicides of 18 prominent individuals in Japan. They noted that the spike in emotional responses on Twitter correlated with a spike in suicide rates in the country.²⁴ In the recent past, after season one of 13 Reasons Why (TRY) was released on Netflix, internet search engines reported an increase in searches incorporating the word “suicide” by nearly 20%.²⁵ Also, mental health professionals heavily criticized TRY for glamourizing suicides in adolescents.²⁵ Several other suicides subsequently reported in the press bore eerie similarities to the suicide portrayed on screen and were highly suggestive of a direct imitative effect.²⁵

The Papageno Effect

On the other hand, responsible media reporting plays a role in mitigating the incidence of suicide. This protective effect has been termed the Papageno Effect, after the character in Mozart’s opera The Magic Flute. When Papageno fears that he has lost his love, Papagena, he prepares to hang himself. However, three child-spirits intervene and advise him to play his magic bells instead, summoning Papagena. He is thus rewarded by union with his love, perhaps as a tribute to resilience. Similarly, after the death of Kurt Cobain of suicide, responsible media reporting and discussion of mental health by his friends and family ensured that the imitative effect was kept to a minimum.²⁶

Relevance in the Current Scenario

In India, in recent years, there is indeed an increase in the incidence of suicide. The COVID-19 pandemic and lockdown have seen an increase in depression, anxiety, and suicide in the general population.^{3, 4, 8, 9} Mr Sushant Singh Rajput’s death appears to have, in this context, been followed by a similar rise in imitative suicides. In major cities such as Kolkata, Delhi, and Bangalore, about 20 people ended their life recently, in a way suggestive of this imitative effect.¹⁵ Multiple interlinked stressors, including lockdown-related unemployment, financial constraints, curbs on movement, the paucity of communication, loneliness, and social isolation, further complicate mental health of the community.

In this difficult time, the predominant modes of mass communication are social media and news reporting. When much of the news coverage is negative and related to the COVID-19 pandemic, speculation about the postpandemic situation, doomsday theories, political tensions, border conflicts, and hate crimes, they are bound to have synergistic effects on the public well-being. An overwhelming amount of new data is constantly generated, causing information overload, compassion fatigue, and emotional burn out. Responsible news reporting of suicides, in this context, is much required to veer away from sensationalizing suicide as a way out of an uncertain and ambiguous situation.

In the current context, there has also been an increase in condemnatory statements and threats, issued by the public and on social media, to people Mr Rajput was associated with in a professional or personal capacity.

We postulate that sensationalist media coverage and public statements by mental health professionals may also contribute to a potentially volatile situation in the aftermath of a celebrity suicide. Such statements are a breach of the Hippocratic Oath and rules of professional conduct. Further, there is potential for even well-meant statements to be interpreted out of context. With regard to Mr Rajput, sensationalist coverage has unfortunately been associated with an increase in hate speech and activities toward persons considered responsible, including through social media. Similar attacks were seen directed toward an ex-partner in the aftermath of Heath Ledger’s death. This is regrettable.

The Goldwater Rule

A survey on the mental health of Sen0ator Barry Goldwater, by the editors of Fact magazine, during the 1964 presidential campaign in the USA is believed to have played a role in his subsequent loss to President Lyndon Johnson. Several mental health professionals participated in the survey, expressed views on his mental health, and offered diagnoses, many of which were colored by their personal political biases. This led to the framing of the Goldwater Rule by the American Psychiatric Association. The rule applies to public figures, and states: “[I]t is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”²⁷ Psychiatrists have been inconsistent in their adherence to the rule, with elections in the world’s two largest democracies—India and the USA—being marked by public speculation on the mental health of politicians.^{28, 29} Detailed coverage of ethics in political discourse is outside the scope of this article. However, the publication by the IPS of an equivalent of the Goldwater Rule may help ensure better and more conscientious discussion of the mental health of public figures and avoid voyeuristic and intrusive speculation, as, unfortunately, occurred in this case.

With regard to Mr Rajput, statements were made by mental health professionals around the world about his mental health and speculating upon reasons for his suicide, including discussion of personal details and relationships. We would like to note that this would be a breach of both the Hippocratic Oath and the Goldwater rule, in addition to a respect for privacy.

Resources on Responsible Reporting of Suicides

The World Health Organization (WHO) in 2000 provided an important resource document for professionals in media and related areas of work on how suicide may be reported responsibly and linked to public health education about mental health and suicide prevention.²⁸ Adherence to these and other public health guidelines have been sparse and partial. A study by Chandra et al. on whether 341 newspaper reports of suicides comply with standard suicide prevention guidelines found that 89% of newspaper reports mentioned the method of suicide, 90% the name of the person, 95% the gender, 80% the age, and 75% the life events related to suicide. In total, 69% carried headlines related to suicide, and 32% placed the reports in prominent sections of the newspapers. Hearteningly, news reporting in vernacular languages appeared to comply with guidelines to a higher degree than those in the English language.²⁹

A more recent analysis of three newspaper reports, two of which were in a vernacular language (Malayalam) and one in English (all three were published on 15 June, 2020) found, on the other hand, that the English newspaper report adhered to IPS and PCI guidelines more closely than the vernacular newspaper report.³⁰ Repetitive reporting in newspapers was noted for several days after the demise. However, the study found that no newspapers carried positive messages from mental health experts or celebrities who had survived suicidality and mental illness.³⁰

Guidelines on the responsible reporting of suicide and mental illness were released by the IPS in 2014 and the PCI in 2019.^{31, 32} However, as with the WHO guidelines, since these are not legally binding, adherence in Indian news reporting is erratic.²⁸

Contextualizing this in the light of the recent death by suicide of Mr Sushant Singh Rajput, it is clear that nearly all recommendations by the WHO, the IPS and the PCI as well by mental health and press professionals were flaunted, with adverse effects on a country already struggling to grapple with several unprecedented humanitarian crises.

Discussion and Recommendations

Robust data indicates that responsible reporting and ethics in journalism benefit public mental health.^{33, 34} Simple and easily achievable strategies such as like disinvesting in the lurid description of suicidal thoughts, the modus of suicide, voyeuristic speculation about the professional and personal lives of public figures, conspiracy theories, or romanticization of suffering and death can contribute to better community mental health. A greater focus on mental health, destigmatization of mental illnesses, discussion of resilience and coping mechanisms, information about helplines, and improving access to affordable mental health care can help people considerably.^33–35

It is further recommended that individuals and commercial enterprises refrain from making a professional opportunity out of the tragic death of a public figure by suicide. Several public figures, mental health professionals, and lifestyle advisors have appeared in news coverage, discussing their personal relationship with or proffering a professional opinion of Mr Sushant Singh Rajput. This may be best avoided, from an ethical and public health perspective. Mental health professionals considering a public statement in the aftermath of a publicized death due to suicide may be recommended to discuss such with their professional bodies and do so with caution.

Although the IPS and other professional bodies and/or leading institutes have published suicide prevention guidelines in the Indian context, these recommendations often remain on paper and do not appear to translate to public health policy.^{28, 31, 32} Guidelines on responsible reporting by the WHO, IPS, and PCI, too, remain on paper.^{28, 31, 32}

The Centre for Mental Health, Law and Media Policy has given seven recommendations, based upon the WHO guidelines, on responsible media reporting of the death by suicide of celebrities^{36, 37}:

1. Do not promote suicide stories by placing them in the front pages of the newspaper or as a lead item in broadcast media.

2. Do not give details about the method or location of any suicide death or attempt.

3. Suicide notes, text messages, social media posts, or emails of the deceased person and/or their family members should not be published.

4. Do not speculate. Verify your facts from multiple sources when the reasons for a suicide death or attempt are not immediately clear.

5. Do not reveal personal details about family members, the deceased person, or any person who has attempted suicide, without their informed consent.

6. Do not write of suicide deaths/attempts as horrific, unfortunate events. Open your story by focusing on the celebrity’s life and their contribution to society.

7. Suicide is a largely preventable public health problem. Several counseling services and helplines across the country work for this cause. Include these resources in your story/report.

Guidelines such as these are a valuable resource that may be utilized for responsible reporting and in professional discussions upon the death and mental health of a prominent person.

On a positive note, many national newspapers appear to now adhere to mental health guidelines, which is commendable. The media has also helped emphasize the importance of mental health hand highlight the ways and means of seeking help, and have published helpline numbers prominently, which hopefully will have a positive impact on public health and perception.¹² Adolescents and young adults are highly vulnerable to the vicissitudes of the COVID-19 pandemic, imitative suicides, and suicidality.³⁸ School- and college-based outreach programs, including integration with digital academic platforms and telepsychiatry programs, may be helpful during this period. Targeted suicide prevention interventions directed toward this vulnerable age group could be recommended.

Finally, respect for professional and personal boundaries in life and death, responsible reporting, ethics in health care and journalism, destigmatization of mental illnesses, improved access to and affordability of mental health care, and strategic investment in mental health in public health policies and programs may go a long way toward better mental health for all and lower suicide rates.^{39, 40} May we all remember to accord due dignity and respect for privacy in death and dying, to ourselves and each other.⁴¹

Acknowledgments

The authors acknowledge using the names of Ms Marilyn Monroe, Mr Sushant Singh Rajput, Mr Robin Williams, Mr Heath Ledger, and Sen Barry Goldwater in the manuscript. The disclosure of identity is regretted. However, it would have been impossible to contextualize our viewpoint without invoking real world examples.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.