Asian Journal of Psychiatry 74 (2022) 103172

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Awareness and preferences about suicide crisis support service options

among college students in India: A cross sectional study
Anish V. Cherian a, *, Vikas Menon b, Bharath Rathinam a, Agnieta Aiman c, U. Shrinivasa Bhat c,
Praveen Arahantabailu d, Soyuz John d, Shishir Kumar c, Aneesh Bhat e
a
National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
b
Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
c
Department of Psychiatry, K S Hegde Medical Academy, Nitte Deemed to be University, Mangalore, India
d
Department of Psychiatry, Kasturba Medical College, Manipal, India
e
Department of Psychiatry, Maharashtra Institute of Medical Education and Research (MIMER), India

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Our objective was to explore the awareness about suicide support services and preferred service
Suicide options during a suicide crisis among college going young adults.
Attempted suicide Methods: Between September 2016 and February 2017, we invited students from colleges affiliated to three major
Crisis support
universities in a coastal district of South India to participate in a cross-sectional survey.
Mental health services
Helplines
Results: A total of 1890 usable responses were obtained. Most participants (n = 1633, 86.4%) were unaware of
Young adults any suicide crisis support options. Most commonly listed options were support from family members, peer
groups, counselling and psychiatric consultation. These were also endorsed as most preferred support options.
Conclusion: There is a low level of awareness about suicide support services among young Indian adults. There is
a need for coordinated efforts to raise awareness and promote uptake of suicide support services in this group.

1. Introduction young Indian adults.

Sixty percent of the world’s suicides occur in Asia (Beautrais, 2006;
Chen et al., 2012; WHO | Suicide and Suicide Prevention in Asia, n.d.).
India is home to highest number of 10–24 years old with 242 million
young people (Social Statistics Division, 2017) and suicide ranks as the
major cause of death in this age group (Chen et al., 2012; Sagar et al.,
2020). Suicide among younger adults has substantial impact on the
potential years of life lost, associated socioeconomic burden, and sub­
sequently on the nation’s Gross Domestic Product (GDP) (Poduri, 2016).
Increasing suicide awareness is often positioned as the first step and
primary component for any suicide prevention program (Grandin et al.,
2001). In college settings, student awareness about suicidal behavior of
individuals in their close proximity can empower them to offer help
(Cerel et al., 2013). In this regard, lack of awareness about suicide crisis
service options can become a barrier for professional help seeking.
Though facilitators and barriers to professional help seeking for mental
health issues has been explored among young people (Sanghvi and
Mehrotra, 2021), there is a dearth of information on awareness of and
comfortability with available crisis service options for suicide among
Therefore, as a first step towards engaging youth in suicide preven­
tion and intervention strategies, our study tried to explore their
awareness about and preferences for using crisis support service options
among college going young adults.
2. Methods
2.1. Study setting and participants
This was a cross-sectional survey involving undergraduate students
aged between 18 and 21 years from various study streams, all of whom
were fluent in reading, writing, and comprehension of English &
Kannada. Recruitment sites were multiple colleges affiliated to two
major universities in Mangalore, South India.
2.2. Data collection measures
The interview schedule was constructed by the research team to
document relevant socio-demographic data, suicidal ideation, attempt,

* Corresponding author.
E-mail address: anishvcherian@gmail.com (A.V. Cherian).

https://doi.org/10.1016/j.ajp.2022.103172
Received 6 April 2022; Received in revised form 9 May 2022; Accepted 11 May 2022
Available online 13 May 2022
1876-2018/© 2022 Published by Elsevier B.V.
A.V. Cherian et al. Asian Journal of Psychiatry 74 (2022) 103172

Table 1 Table 2
The socio-demographic details of the participants. The cumulative frequency (in percentage) of awareness of crisis-support options.
DOMAINS N (%) /mean (SD) SUPPORT OPTIONS % OF STUDETNS AWARE OF THE
SUPPORT OPTION
Age 18.91( ± 1.47)
Gender SMS services 5.28
Females 1401 (74.07) Online service user forum 4.28
Males 489 (25.87) Android/IOS services 6.42
Religion Online chat (24 *7) 8.91
Hindu 648 (34.29) Crisis phone lines (24 *7) 9.24
Muslim 267 (14.13) local hospital/GP 8.92
Christian 882 (46.67) Peer group (friends) 11.46
Others 70 (3.70) Psychiatric consultations 13.05
Stream of study One to one (face to face) counselling 14.75
Medical/Paramedical 423 (22.38) Support from family members/ 17.70
Science/Engineering 384 (20.32) relatives/teachers.
Humanities 282 (14.92)
Commerce/Management 797 (42.16)
Family type Karnataka, India and also obtained approval from the college authorities
Nuclear 982 (51.96) to contact the student’s in college premises to conduct the survey. Those
Joint 640 (33.86)
Extended 158 (8.36)
above 18 years provided a written informed consent for participation;
Living alone 42 (1.80) for others, a written assent was obtained.
Others 76 (4.02)
Use of internet 3. Results
Yes 1700 (89.95)

3.1. Participant characteristics

information related to awareness, and preferences of crisis intervention
services. First, a detailed literature review was performed to formulate
the items of the schedule. The research team assessed all the items for
their comprehensibility and acceptability. Disagreements were resolved
by mutual discussion till consensus. Next, the schedule was given for
independent assessment of six mental health experts. The expert team
comprised of psychiatrists, psychologists, psychiatric social workers,
under-graduate faculty, and youth representatives and a consensus was
arrived at on the final items in the schedule.
Participants were asked about the preferred crisis support options
namely crisis phone lines, online chat, one to one (face to face) coun­
selling, short messaging services (SMS), psychiatric consultations,
Android/iOS app-based services, peer support groups (friends), online
service user forums, visit to medical professional (local hospital, family
doctor, general practitioner, or physician), and support from family
members/relatives/teachers. Responses to awareness of support services
were dichotomous (yes/no) followed by a probe to elicit service options
known to them (eg: Are you aware of the support services available if
you were to experience suicidal thoughts. If yes, what are they?) Qual­
itative responses for this probe were manually coded into the following
categories: counselling/psychiatric service, social support (teachers/
parents/friends), recreational activities (music, sports), deliberate self-
harm, and faith in religion/God. A five-point Likert scale ranging from
very likely to very unlikely was employed to capture the preference for
using the available support service options. Different crisis support op­
tions in Indian context are enumerated in SL-Table 1.
2.3. Data collection procedure
The research team approached all the colleges affiliated to the three
major universities in Mangalore that offered undergraduate degrees.
After obtaining permission from the college authorities, the research
assistants approached undergraduate students during their free hour in
their classrooms on the designated days of data collection. Students were
informed about the nature of the study and invited to complete the
assessment tools. Collection of data was carried out over 6 months
starting from September 2016 to February 2017.
2.4. Ethical aspects
The study protocol was approved by the institute ethics board of K. S.
Hegde Medical Academy, NITTE Deemed to be University, Mangalore,
The research team approached over 3985 college students across
various study streams of whom 1890 students agreed and provided
complete responses. The age of the participants ranged from 17 to 26
years. Participants were predominantly female (74%) and hailed from
nuclear families (52%). Majority of the participants (90%) reported that
they use internet every day. Other socio-demographic details of the
study participants are shown in Table 1.
3.2. Awareness of suicide support options
Around 257(13.6%) of participants reported that they were aware of
some sort of suicide crisis support. Support options most frequently
listed were support from family/relatives/teachers, peer group, one-to-
one counselling, and psychiatric consultation in that order (Table 2);
these were also the ones they were most likely to use and most
comfortable with, if needed. Crisis support options like online chat,
helplines and local hospital/GP were the next common ones listed. On
the other hand, SMS, online service user forum, and Android/IOS ser­
vices were less commonly listed, less likely to be used, and least
comfortable support options.
4. Discussion
This study examined Indian college students’ awareness and pref­
erences for different crisis support options for help during times of sui­
cidal crisis. Only a small proportion of participants (13.6%) were aware
of some crisis service option. Poor awareness reduces rates of service
utilization and can pose a challenge to timely care delivery. Institution-
based awareness programs such as induction or orientation programs
can be used to raise awareness about and sensitize participants towards
suicide prevention (Nebanani and Singhai, 2019). Poor awareness about
suicide prevention services also point to the need for universal strategies
like public awareness campaigns, education and information dissemi­
nation through infographics, leaflets, and newsletters, and college-based
crisis intervention programs.
Interestingly, one of the support options reported by participants to
cope with a suicidal crisis was deliberate self-harm. Studies have indi­
cated that self-harm among youth is often performed to regulate internal
emotional states (Kharsati and Bhola, 2015). Further, faith in religion or
god was endorsed as a crisis service option; this may either reflect
culturally sanctioned ways to deal with distress or stigma against mental
illness which prevents utilization of formal services (Sanghvi and

2
A.V. Cherian et al.
Fig. 1. The likeablity of the college students about possible crisis support options.
Fig. 2. The comfortability of the college students about using the possible crisis support options.
Mehrotra, 2021). Prevention programs must, therefore, be sensitive to
these cultural perceptions and negative coping strategies used by young
adults.
Counselling or psychiatric services and social support (teachers/
parents/friends) were commonly listed and preferred service options.
Hence, a connectedness based approach may have value as a suicide
prevention strategy for college students; such strategies have been found
to have salutary effect in suicide prevention (Nebanani and Singhai,
2019; Whitlock et al., 2013). Further, gatekeeper models can be adapted
to train teachers and peers to recognize key behavioral red flags indi­
cating elevated suicide risk among students and refer them for appro­
priate professional help (Menon et al., 2018; Sagar and Pattanayak,
2016).
Lower rate of awareness and preference was reported for technology-
based services like SMS, online service user forums, mobile apps, help­
lines, and online chat. Awareness about social media related suicide
support options were not specifically evaluated; however, given the
study period (2016–17) and given the low levels of awareness about
SMS and mobile apps-related options, we speculate that social media-
related options would have generated similar responses. This was
somewhat counter-intuitive as one would expect students of today’s age
to be familiar with internet-based crisis intervention services. Our
3
Asian Journal of Psychiatry 74 (2022) 103172
findings were comparable with studies from developed nations where
awareness of crisis helplines was low compared to awareness of face-to-
face methods of support (Arria et al., 2011; Crosby Budinger et al., 2015;
Gould et al., 2006). This may reflect a lack of penetration and uptake of
online suicide support services. Nonetheless, technology-based services
may hold especial significance in low resource settings to bridge care
delivery gap in suicide prevention services and merits further study;
preliminary evidence in this direction is available (De la Torre et al.,
2017).
The current study had a relatively large sample and examined
awareness about suicide support services among young adults, an area
where little information is available but nonetheless significant due to
the considerable impact and rate of suicide in this group. However, a few
study limitations must be kept in mind. A systematic multistage sam­
pling could have increased the fidelity of responses and reduced selec­
tion bias. Incomplete responses while filling the questionnaire resulted
in missing data. (Figs. 1 and 2).
5. Conclusion
Young adult students in the Indian context have low awareness about
suicide support services. They prefer to use family and peer group-based
A.V. Cherian et al.
support and mental health services during a crisis. Academic institutions
may strive towards building an ecosystem of connecting informal and
formal support systems for enhancing the early identification of suici­
dality among students. Campaigns for enhancing awareness about and
acceptance towards technology-based crisis intervention services would
help to close the treatment gap in suicide in this group.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.ajp.2022.103172.
References
Arria, A.M., Winick, E.R., Garnier-Dykstra, L.M., Vincent, K.B., Caldeira, K.M., Wilcox, H.
C., O’Grady, K.E., 2011. Help seeking and mental health service utilization among
college students with a history of suicide ideation. Psychiatr. Serv. 62 (12),
1510–1513. https://doi.org/10.1176/appi.ps.005562010.
Beautrais, A.L., 2006. Suicide in Asia. Crisis 27 (2), 55–57. https://doi.org/10.1027/
0227-5910.27.2.55.
Cerel, J., Bolin, M.C., Moore, M.M., 2013. Suicide exposure, awareness and attitudes in
college students. Adv. Ment. Health 12 (1), 46–53. https://doi.org/10.5172/
jamh.2013.12.1.46.
Chen, Y.-Y., Chien-Chang Wu, K., Yousuf, S., Yip, P.S.F., 2012. Suicide in Asia:
opportunities and challenges. Epidemiol. Rev. 34 (1), 129–144. https://doi.org/
10.1093/epirev/mxr025.
Crosby Budinger, M., Cwik, M.F., Riddle, M.A., 2015. Awareness, attitudes, and use of
crisis hotlines among youth at-risk for suicide. Suicide Life-Threat. Behav. 45 (2),
192–198. https://doi.org/10.1111/sltb.12112.
De la Torre, I., Castillo, G., Arambarri, J., López-Coronado, M., Franco, M.A., 2017.
Mobile apps for suicide prevention: Review of virtual stores and literature. JMIR
MHealth UHealth 5 (10), 1–5. https://doi.org/10.2196/mhealth.8036.
Asian Journal of Psychiatry 74 (2022) 103172
Gould, M.S., Greenberg, T., Munfakh, J.L.H., Kleinman, M., Lubell, K., 2006. Teenagers’
Attitudes about Seeking Help from Telephone Crisis Services (Hotlines). Suicide Life-
Threat. Behav. 36 (6), 601–613. https://doi.org/10.1521/suli.2006.36.6.601.
Grandin, L.D., Yan, L.J., Gray, S.M., Jamison, K.R., Sachs, G.S., 2001. Suicide prevention:
Increasing education and awareness. J. Clin. Psychiatry 62 (SUPPL. 25), 12–16.
Kharsati, N., Bhola, P., 2015. Patterns of non-suicidal self-injurious behaviours among
college students in India. Int. J. Soc. Psychiatry 61 (1), 39–49. https://doi.org/
10.1177/0020764014535755.
Menon, V., Subramanian, K., Selvakumar, N., Kattimani, S., 2018. Suicide Prevention
Strategies: An Overview of Current Evidence and Best Practice Elements. Int. J. Adv.
Ment. Health Res. 5 (1), 43–51. https://doi.org/10.4103/IJAMR.IJAMR.
Nebanani, N., Singhai, K., 2019. Suicide prevention strategies for adolescents and youth:
Where are we missing? J. Indian Assoc. Child Adolesc. Ment. Health 15 (2), 1–12.
Poduri, G.S., 2016. Short-term Cost of Suicides in India. Indian J. Psychol. Med. 38 (6),
524–528. https://doi.org/10.4103/0253-7176.194912.
Sagar, R., Dandona, R., Gururaj, G., Dhaliwal, R.S., Singh, A., Ferrari, A., Dua, T.,
Ganguli, A., Varghese, M., Chakma, J.K., Kumar, G.A., Shaji, K.S., Ambekar, A.,
Rangaswamy, T., Vijayakumar, L., Agarwal, V., Krishnankutty, R.P., Bhatia, R.,
Charlson, F., Dandona, L., 2020. The burden of mental disorders across the states of
India: the Global Burden of Disease Study 1990–2017. Lancet Psychiatry 7 (2),
148–161. https://doi.org/10.1016/S2215-0366(19)30475-4.
Sagar, R., Pattanayak, R., 2016. Suicidality and mood disorders: Gatekeepers′ training
and mental health first aid. J. Ment. Health Hum. Behav. 21 (2), 85. https://doi.org/
10.4103/0971-8990.193424.
Sanghvi, P.B., Mehrotra, S., 2021. Help-seeking for mental health concerns: review of
Indian research and emergent insights. J. Health Res., Ahead–p(Ahead–Print. ).
https://doi.org/10.1108/jhr-02-2020-0040.
Social Statistics Division, 2017, Youth in India. In Youth in India. 〈https://doi.org/10.4
324/9780367142049〉.
Whitlock, J.L., Wyman, P.A., & Barreira, P., 2013, Connectedness and suicide prevention
in college settings: Directions and implications for practice (Issue June 2014)
[University of Rochester]. 〈https://www.researchgate.net/publication/234814889_
Connectedness_and_suicide_prevention_in_college_settings_Directions_and_
implications_for_practice〉.