Suicide is described as an unforced and willing termination of one’s life, and it is a complex incident that suddenly ends the lifecycle. People (close ones to general population at large) are often unaware why someone committed suicide or ended their life. Thus, many times the surroundings explain the factors, features, reason, and conditions that led to the person’s suicide. One cannot establish or give a final statement on the issue as the person who did it, is not available to contribute to the investigation. It is challenging to gather thorough and reliable information because of the variety of interactions with the family and the contradictory information they may provide. The rate of suicide in the geriatric population is high and strategies are needed to address this. In order to gather more information on the topic and become aware of the issues, we need to carefully observe the factors and contexts of suicide in the geriatric population. We must be careful to explain these issues as when the suicidal individual is elderly it is more difficult to gather the data. However, based on the findings of some South East Asia (SEA) region-based researchers and a few other studies the authors tried to observe and explain the challenging paradigms to attributes and context of geriatric suicide.

Suicide in the geriatric population is a significant problem. The geriatric population has unique issues like retirement, loss of job, dependency on others for daily needs, loss of spouse/close friends, medical illnesses, loneliness and isolation, which makes them vulnerable for enormous distress. ¹ Suicide is often multifactorial and the result of close, intense interaction between several biological, psychological and social factors. ² In a retrospective study over 37 years, it was found that negative mental state is an important predictor of suicide in elderly, whereas chronic medical illness and significant psychological distress are important predictors of suicide in older men. ²

As per the report of the American Association for Marriage and Family Therapy (AAMFT), in the United States (US), suicide in older adults is responsible for 18% of all suicide related deaths, though older adults represent 12% of the US population. ³ Increasing age, being separated from their spouse, and being a white male are important determinants of suicide in older adults. ³ However, having a psychiatric illness, particularly depression, is also an important predictor of suicide in older adults. ³ The elderly population in South East Asia is rapidly growing and the number of elderly people with mental illness and/or medical comorbidities is also increasing rapidly. ⁴ Hence, it is anticipated that the number of suicides among the elderly population will grow significantly. So, it is obvious that the contexts and attributes of suicide in the elderly population will be different from that of adult population. The suicide rate in the South East Asia region was estimated to be 17.7 per 100,000 population. ⁵ The rate of suicide in the elderly population and adolescents is found to be higher than the adult population and there is gross variation in the prevalence of suicide across the South Asian countries. ⁵ Hanging is found to be the common mode of suicide in older adults. ²

In the South East Asia region, the male to female suicide ratio is higher (close to 1) than the rest of the world (3:5). ⁵ The factors and attributes of suicide may vary from region to region due to socio-cultural and geographic diversities. Understanding these factors may help in planning the suicide prevention strategy for elderly population.

It has been reported that 10% world’s suicides take place in India, Pakistan and Sri Lanka. ⁶ Jordan et al.(2014) cited in their scoping review that the suicide rates in South Asia can be compared to the global average and it is men who commit suicide than the women. ⁷ The suicide rate among the South Asian population ranges between 0.43/100000 to 331.0/100000 of the population and the rate varies between countries, and is mainly linked to the development levels (countries with different developmental indexes have different suicide rates; there is also significant regional variations). ⁷ Various researchers conducted studies at various points of time in different regions and found gross variations in suicide rate. ⁷ The prevalence rate of suicide in studies conducted in India ranges between 11.7 per 100000 population to 189.0 per 100000 population, whereas in Bangladesh (6.6 to 128.8 per 100000), Pakistan (1.1 to 14.9 per 100000), Nepal (7.0 per 100000) and Sri Lanka (19.6 to 24.1 per 100000) the rates are different, indicating the loco-regional variations. ⁷

Arafat et al.(2021) shared that hanging and poisoning were the most common suicide methods in Bangladesh and India, and poisoning was the preferred method of suicide in Sri Lanka. ⁸ However, their review concluded that hanging is the most common method of suicide in South Asia. In India, most suicides are reported as due to personal or social reasons, followed by health and other reasons. ⁹ Chandrasekaran and Gnanaselane (2008) investigated the predictors of repeated suicide attempts of 348 samples from India and found that repeat suicide attempts are associated with depression, hopelessness and suicidal intent, and presence of major depression and social dissidence are predictive factors for repeat attempts. ¹⁰

A recent scoping review by Arafat et al. (2022) revealed that the prevalence of depression among fatal (37.3%) and nonfatal suicidal attempts (32.7%) in South Asian countries seems to be lower compared to other regions of the world. ¹¹ In another research, Arafat et al. found that the presence of preexisting psychiatric morbidities and stressful life events are the most common risk factors for suicide in South Asia. ¹²

The rapid growth of the geriatric population is one of the important facts of the 21 ^st century. ¹³ Suicide among the elderly people is considered as a major public health concern and it is associated with complex underlying psychosocial, physical and mental health issues faced by the elderly population. ¹⁴ Additionally, marital conflict, feelings of hopelessness due to being alone, and being a widow are the potential risk factors for suicide among the older population. ¹⁵

Suicidal behavior among elderly population is grossly under-studied in Bangladesh. One recent review identified only one study assessing the depression and suicidal thoughts among rural elderly people of Bangladesh. ¹⁵ The study revealed that 23% of 625 participants had suicidal thoughts. The frequency of suicidal thoughts was significantly higher among illiterate persons, women, and those living without partners. Living with family members and having a good contact with them were identified as protective factors in Bangladesh. ¹⁶ Amudhan et al. (2020) analysed the national mental health survey data from India and reported that India accounts for 26.6% of global suicide deaths, and that the prevalence was higher among those over 60 years of age. ¹⁷ However, Philip et al. (2022) found that there is a slight modest increase in the suicidal rates among people 60 years and over and the rates were higher among elderly women compared to elderly men in India. ¹⁸

Shoib et al. (2020) found that depression along with hopelessness are the key contributing factors of suicidal behaviours among the geriatric population in Kashmir, India. ¹⁹ In Sri Lanka, about 23.6% of deaths among the elderly population were reported to be suicides. ¹⁴

As discussed above, given its high rate of suicide, South East Asia can be considered the hub of suicide. There are certain factors that make the South East Asian population unique and different from the rest of the world. These factors are: 1.

Religious and cultural diversity: South East Asia is the hub of multiple religious practices. Different religions have different notions related to suicide. Some religion condemn suicide considering it as a sin; whereas several religions glorify self-sacrifice. This largely influences the suicidal behavior.

Marriage, divorce, and alcohol consumption are other important determinants of suicide. ⁴⁷ The geriatric population is increasing globally, including in South-East Asian countries. ⁴⁸ It has been anticipated that the geriatric population of South-East Asia will rise exponentially by 2050, and thus the suicide rate and total number of suicides in the geriatric population will also increase. ⁴⁸

Research evidence suggest that during the period of economic crisis (1997-1998), there was an increase in suicide rates in most South East Asian countries. ⁴⁷ The increase in suicides cannot be exclusively attributed to the financial crisis, however. Evidence suggests that in South East Asia, affluent countries have a higher suicide rate, ⁴⁹ which indicates that there may be other attributing factors, specific to countries and regions, which are associated with suicide.

Grief is an important modulating factor for suicidal behavior, and complicated grief is common following natural disasters. As South East Asian countries commonly encounter natural disasters, their significant impact on mental health and suicidal behavior cannot be ignored. ⁵⁰

The COVID-19 pandemic affected the elderly population significantly. Lockdown-related restrictions, medical morbidities, isolation, limited recreational opportunities, loss of spouse and fear of COVID-19 had a cumulative effect that affected the mental well-being of the elderly population significantly. ⁵¹ There are significant regional variations in COVID-19 globally, and South East Asia was one of the worst affected regions. Comparisons of suicide rates between 1979 and 2014 revealed that Taiwan, Hong Kong, and Japan have lower male to female suicide rates in comparison to Australia and New Zealand in the adult population; however, in the elderly population the suicide rate varies across the countries. ⁵² Similarly, there is also a difference in mode of suicide in different age groups, and across rural and urban areas. ⁵³

From the research perspective, a significantly higher number of suicides are occurring in South East Asian countries; however, most researches on suicide are from developed countries like the USA, UK, Australia. ⁴⁸ Whatever research data exists, mostly are in reference to completed suicide. ⁵⁴ Though the number of suicide attempts are much higher than the number of completed suicides, the research on these population are sparse.

Prevention of suicide among the geriatric population is still an untapped area in South Asia due to a dearth of studies assessing the risk factors for suicide in the region. Adequate research assessing the risk factors and effectiveness of interventions, identifying local resilience factors, trained manpower, funds, and proper services settings is necessary to prevent suicide in the geriatric age group in SEAR. Likewise in other age groups, the biopsychosocial approach could be attempted in SEAR countries. ¹⁴ Medications can be considered to treat depression or psychiatric disorders as a biological approach, problem solving psychotherapy, cognitive behavior therapy, or other appropriate approach of psychotherapy can be used as a psychological approach, and finally managing social events and ensuring a supportive social environment can be targeted as a social approach.

Suicide among the elderly population is a serious issue. Ageing, living alone, having a mental health condition, and having coexisting physical conditions have all been recognized as risk factors for suicide in the older population. In South East Asia, both the elderly population and the number of elderly people with mental illness and/or medical comorbidities are growing quickly. Due to geographic and socio-cultural differences, there may be regional variations in the causes and characteristics of suicide. Planning the elderly population's suicide prevention approach may be aided by having a better understanding of these issues. Studies investigating the demographics, risk factors, and prevention of suicide among the senior population in the area are scarce. Primary care doctors, specialized mental health support, gatekeeper training, means restriction, raising awareness, a supportive family environment, and a dedicated call center could be feasible strategies for preventing suicide among the elderly in the area. To develop successful suicide prevention techniques, additional research is required.