Bertolote et al (Reference Bertolote, Fleischmann and Eddleston2006) report the global response to deaths from pesticide poisoning. Suicide rates in southern India have been reported to be high (Reference Joseph, Abraham and MuliyilJoseph et al, 2003; Reference Aaron, Joseph and AbrahamAaron et al, 2004; Reference Abraham, Abraham and JacobAbraham et al, 2005; Reference Prasad, Abraham and MinzPrasad et al, 2006), with 1741 suicides documented in a population of about 100 000 from 1986 to 2005. Hanging (804 of 1741, 46.2%) and poisoning (746 of 1741, 42.8%) were the methods most commonly employed. Although people under 40 years tended to use poisons, older people tended to choose hanging (χ²=36.71, d.f.=4, P < 0.001). Significantly more males (465 of 984, 47.3%) than females (281 of 757, 37.1%) (χ²=17.6, d.f.=1, P < 0.001) chose death by poisoning. There was no significant change in the overall rate of suicide or the method employed during the period. Detailed analysis of the data from 2001 to 2005 revealed that only 68% of the fatal episodes of self-poisoning were a result of ingestion of pesticides.

Self-poisoning with pesticides is a significant public health problem in low- and middle-income countries. The majority of such poisoning occurs in rural agrarian households. Some suggestions to reduce such deaths are currently difficult to implement. Enforcing the hazardous chemicals and wastes conventions to restrict and control the sale and use of pesticides in such regions is no small task and requires major political, administrative, financial and social commitment. Given the many competing demands on limited governmental resources in low- and middle-income countries, such protocols are difficult to implement. In addition, the improved recognition and treatment of mental illness may not have a significant impact on the overall suicide rate as many people in the low- and middle-income countries who die by suicide do not have severe mental illness. Rather, the majority of such attempts are impulsive and follow stressful life events. Although reducing accessibility to pesticides will decrease such impulsive attempts and consequent deaths, social, economic and cultural factors must also be addressed to make a real difference. Thus, although the World Health Organization's intersectoral global initiative is a step in the right direction, it is imperative that practical issues related to its implementation are discussed. It is necessary to consider strategies to encourage governments to set up suicide prevention programmes to reduce suicide rates in populations as a whole rather than method- and site-specific rates.

Suicide in low- and middle-income countries is not only a medical and public health problem but is also related to economics and culture. A coordinated and a comprehensive response is needed to make any impact.