Objectives Crime reports of suicide incidents routinely feature in the Indian mass media, with minimal coverage of suicide as a broader public health issue. To supplement our recently published content analysis study, we undertook qualitative interviews to examine media professionals' perspectives and experiences in relation to media reporting of suicide-related news in India.
Design and setting In 2017–2018, we undertook semistructured qualitative interviews with media professionals with experience reporting on suicide-related news. A semistructured interview guide was designed to initiate discussions around their perspectives and experiences in relation to reporting on suicide. Interviews were digitally audio-recorded and transcribed, and a deductive and inductive approach to thematic analysis was used.
Participants Twenty-eight interviews were undertaken with media professionals in Delhi, Chandigarh and Chennai.
Results A clear role for media in suicide prevention framed around educating and informing the public was articulated by several participants and a majority of participants also reported concerns and anecdotal accounts that their reporting may negatively influence vulnerable people in the population. Nonetheless, a fatalistic attitude towards suicide was evident among several participants including dismissing or minimising concerns around imitation suicides. Several participants also expressed doubts around the quality of suicide helplines in India and were hesitant to add such contact details to their reports. Participants were largely very receptive to the idea of developing voluntary media guidelines for the Indian context, although doubts were raised around compliance unless additional initiatives were taken to engage media professionals at the highest levels.
Conclusions Our findings reveal the perspectives of media professionals operating in the Indian context and can be used to support constructive partnerships between media professionals and suicide prevention experts. There is a clear need for a genuine and sustained partnership between suicide prevention experts and media professionals at all levels.
- suicide & self-harm
- public health
- mental health
- qualitative research
Data availability statement
Data may be obtained from a third party and are not publicly available. All data relevant to the study are included in the article. Raw data cannot be shared publicly due to ethical restrictions. Requests for access to the raw data can be sent to the Human Research Ethics Committee at The University of Melbourne (HREC 1749532.1) at the following email address: HumanEthics-Enquiries@unimelb.edu.au.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
Our previous research identified that reports of suicide incidents are a highly frequent feature in the Indian mass media. In this study we examined the perspectives and experiences of media professionals in relation to reporting on suicide.
We undertook semistructured qualitative interviews with 28 media professionals in Delhi and Chennai across print, TV and online news media, and one-quarter of participants were operating at an editorial level and four were bureau chiefs who held high-level knowledge of reporting practices at their media houses.
The lead author (GA) undertook and transcribed the interviews to enhance familiarisation with the data, and coding was undertaken by two coders (GA and AC) using a mix of deductive and inductive analysis.
Our findings may not reflect the situation outside of Delhi and Chennai, including non-urban settings.
Participants with a special or passionate interest in this issue may have been more likely to offer their participation and we may have missed the perspectives of those media professionals who are more disinterested in the issue.
Southeast Asia accounts for ~40% of suicide deaths globally and is the frontline for delivering on the aspirational Sustainable Development Goal of a one-third reduction in the suicide rate by 2030. Suicide rates in India are among the highest in the world. The most recent suicide rate estimates ranging between 18 and 21 deaths per 100 000 population (cf. 11/100 000 globally), resulting in an estimated 230 000–250 000 suicide deaths annually, which equate to approximately 28% of global suicides (c.f. ~17% of the world population).1 2 Under-reporting of suicide is ubiquitous in the official suicide statistics3 and suicide rates and methods vary substantially across regions.4–6 A public health approach to suicide prevention is gaining momentum in India with calls for the development of national, state and community-level suicide prevention plans and strategies, including the development of media guidelines to improve mass media coverage of suicides.7
Responsible media reporting of suicides has been identified as a promising and potentially effective population-level suicide prevention intervention.8 9 While further research on the impact of media-based interventions is needed, the focus on media portrayals of suicide is based on evidence around copycat suicides, dissemination of suicide methods and behaviours and the imperative to deliver tailored suicide prevention messaging in media content.10–13 There are also important concerns based on observations that media can present simplistic monocausal explanations for suicide and can selectively present ‘newsworthy’ stories that do not reflect the broader array of suicide events in the population, thus impacting the public’s knowledge and beliefs about suicide.14 Empirical research has also observed that the way media reports about suicide are worded and framed can influence the public’s knowledge, beliefs and attitudes about suicide.15–17
Consequently, the WHO has prescribed guidelines for responsible media reporting of suicide.18 However, implementation of the guidelines has been varied, and our previous research found a very high frequency of graphic, explicit and simplistic media reporting of suicide in India, predominantly undertaken by crime journalists.19 We observed that, on average, daily newspapers published one suicide article per day, with the majority being brief (ie, 10 sentences or less) incident reports. Potentially harmful reporting practices were common, such as providing a detailed description of the suicide method, while potentially helpful practices, such as providing contact details for suicide support services, were rare. Similar reporting styles have been observed in neighbouring countries.20–22 We also reported some significant disparities between the epidemiological data on suicide in the population and the stories selectively presented for mass media reports,23 indicative of a process, whereby media determines which suicides are considered newsworthy. Suicides involving women, younger people aged under 30 and those who were students or farmers were among those groups over-reported relative to their occurrence in the broader population. We further documented through qualitative interviews that reporters on the crime beat work in close partnership with police to produce routine and simplified incident report style coverage of suicide incidents, and that suicide reports were used as ‘clickbait’ to generate audience interest.24
The mass media market in India has observed exponential growth and diversification in the number of mass media outlets since the market was privatised in the late 1990s.25 While other countries have observed a decline in print media, India has maintained steady annual growth in terms of publications and income.26 Competition is fierce to attract lucrative advertising revenue, with global commercial interests in the huge number of potential consumers in India and the rapidly expanding middle class aspiring to a ‘Western’ lifestyle.27 As in many countries, this has seen the rapid expansion of a 24/7 breaking news culture. Alongside this trend, the diversity of cultures in India has seen strong demand for a wide array of local/regional news channels, catering to diverse languages and tastes.25 Consequently, we previously documented that suicide stories in the Indian media are overwhelmingly about incidents that were local to the readership base of the publication, rather than incidents from elsewhere in the country or the world.23
In late 2019, after the qualitative data were collected for the study reported on in this paper, the Press Council of India issued a press release, indicating their adoption of the WHO media guidelines,28 although Indian-specific guidelines adapted to the local context are yet to be developed. To help inform future collaborative work with media professionals in India, a crucial next step is to better understand their perspectives and experiences in relation to media reporting on suicide-related news. A review found that there is significant variability in the effect of guidelines on media reporting practices across countries.29 A key concern raised is that in many countries, it is mental health experts who have largely written the media guidelines without sufficient involvement from media professionals.29 Journalists can be sceptical about the association between reporting style and imitative suicidal behaviour and may view any restrictions as censorship,30 that may also perpetuate ‘taboos’ around suicide.31 Media experts further emphasise their important role in ‘agenda-setting’, ‘framing’ stories and ‘priming’ the audience to respond to issues in certain ways, all of which could be tapped into to improve reporting practices.32
In order to facilitate better engagement with media professionals in India, the aim of this study was to examine their perspectives and experiences in relation to reporting on suicide, including their perspectives around the role of mass media in suicide prevention.
In early 2018, semistructured interviews were undertaken with media professionals in India (Chennai, Delhi and Chandigarh) who had previously reported on suicide-related news. The anonymity of participants has been protected so that they could speak freely without concern for their media organisations and colleagues. Participation was voluntary after obtaining written consent.
Due to resource constraints, we focused on recruiting media professionals working in Chennai and Delhi, where we already had established media connections through our research assistants who were veteran media professionals. Both Chennai and Delhi are in the top two cities in India for the highest number of suicide deaths33 and focusing on these two cities allowed us to examine experiences in both the north and the south of the country. Through the recruitment process in Delhi, we were also placed in contact with two additional participants working as media professionals in the smaller nearby city of Chandigarh (estimated population ~1 million), a smaller city to the west of Delhi. Tamil is the official language in Chennai and Hindi is the official language in both Delhi and Chandigarh.
We interviewed 28 media professionals who had experience reporting on suicide. All types of media professionals working for any type of media outlet were eligible to participate. We used purposive and snowball sampling to recruit participants using a mix of strategies, aiming to have a spread of both vernacular and English-language media outlets and a spread of media professionals working across different media formats. A recruitment advertisement was emailed to a diversity of major media organisations in New Delhi and Chennai, seeking participation from media professionals who had previously reported on suicide-related news. This was followed-up shortly afterwards with phone calls to these organisations. Snowball sampling was also used, whereby participants identified other potential participants. We also directly approached a diversity of specific media professionals identified through the networks of our research assistants, who were veteran media professionals.
The sample included a broad diversity of reporters, editors and bureau chiefs, across a wide range of age groups, years of professional experience and media types (see table 1). Half the sample primarily reported in English while the other half reported in Tamil or Hindi, with one participant reporting in Telugu. Just over half the respondents (57%) had crime reporting as their primary area of specialisation.
Media professionals undertook an audio-recorded face-to-face 45 min semistructured qualitative interview with the lead author (GA) to discuss their perspectives and experiences in relation to suicide reporting. Interviews took place at relatively quiet and private locations chosen by the media professionals, which was typically a private room in their workplace, an outdoor setting or a quiet café/restaurant. Semistructured interview guides were prepared, in consultation with veteran media professionals, that evolved as the initial interviews proceeded. The interview guide started by delving into what makes a suicide event newsworthy and the processes and challenges of covering suicide news; the data from these inquiries were analysed for a separate manuscript.24 The guide then turned to inquire: whether media could play a role in suicide prevention; awareness and attitudes towards international media guidelines for suicide reporting; receptiveness to the development of Indian-specific media guidelines for suicide reporting; recommendations and challenges related to the development and implementation of any media guidelines for suicide reporting in India; beliefs and experiences regarding media reports and subsequent imitation suicide events and attitudes in relation to providing contact details for suicide prevention services. Interviews were primarily conducted in English, although three participants requested the support of an interpreter. Interviews continued until we had acquired a diversity of media professionals and a sufficient range of responses with no new themes emerging.
The interviews were undertaken by an Australia-based mental health researcher (GA) who has been working on collaborative research in India for over 10 years, complemented by a team of highly experienced India-based mental health clinician researchers (psychiatry, social work) and veteran media professionals. Our perspective on this research was informed by a suicide prevention and public health lens, more so than a media communications lens, and the analyses presented in this paper were preceded and informed by our prior research into media reporting of suicide in India.19 23 24
Patient and public involvement
This study did not involve patients. Two veteran media professionals were engaged to support the study, including supporting study design and data collection and interpretation.
A deductive and inductive thematic analytic approach was used.34 The lead author (GA) transcribed the interviews to enhance familiarisation with the data and prepared an initial code list of major themes based largely around the topic areas discussed in the interview guide. Two coders (GA and AC) independently read the transcripts multiple times and additional codes were derived inductively for emerging subthemes, which were driven by the data. The two coders discussed differences in their interpretation of results and refined the coding frame accordingly. The lead author subsequently coded all transcripts, using NVivo V.11 software to organise and manage the data. Throughout the analysis, there were several discussions among the research team, including with veteran media professionals, to ensure accurate interpretation of the data.
We identified 5 major themes and 15 subthemes (see table 2), reported in detailed below.
Role for mass media in suicide prevention
The first major thematic area was media professional’s perspectives on whether mass media has a positive role to play in suicide prevention. The notion that mass media might have a role in suicide prevention was a novel idea for most participants, although some participants did express a perspective that largely fell along the lines of two subthemes: ‘informing and education’ and ‘doubts around preventability of suicide’.
Informing and educating
Some participants were receptive to the idea that media has an important role to play by improving its messaging to the public in relation to suicide prevention. The dominant mode of suicide reporting takes an incident report style and is developed by crime reporters, which was seen to miss the opportunity to inform and educate the public in relation to suicide prevention. ‘Media could inform and educate society about suicide and depression… [to help bring] down the suicide cases… If you have some suicide experts that can enrich the story and we can talk with them about why suicide happens’. (Bureau Chief #1, Delhi). In stark contrast to the daily incident report style suicide news produced by crime reporters, it was articulated that media could do a number of things to have a protective effect on the population. As explained by one editor, when reflecting on how media can support suicide prevention among students (a high-profile issue in India):
We can highlight the helplines, the solutions, the indicators that one must look out for… we can give advisories to parents to avoid placing so much pressure on students during exams and to advise on the risk signs to look for, like not talking too much, avoiding eye contact, you know. We can underplay some suicide news, to avoid making it big news. We should avoid giving students the idea that suicide is a solution to their problems, particularly at exam time. (Editor #2, Delhi)
Participants reflected on the speed of the news routine, which impeded quality reporting on suicide and saw suicide events being covered as breaking news before there had been the appropriate investigations. A senior reported suggested that: ‘we should investigate thoroughly before putting the story out, also, once in a week, television channels and newspaper columns could carry a suicide prevention story… media has the power to help bring down the number of suicides’ (Senior Reporter #6, Chennai).
A common suggestion was that media ‘give messages that suicide is not the solution, the suicide awareness should be there’ (Senior Reporter #7, Chennai). Such that, ‘instead of just reporting it, you tell people that there’s a way to prevent it… so we write, “don’t do it”’ (Reporter #1, Chennai). Participants in Chennai gave the example of a high-profile suicide event that was daily news for several weeks, where ‘a Dalit girl and doctor aspirant who committed suicide in protest over an issue with the national medical entrance exams’ (Editor #5, Chennai). Participants reported that they ran lines in their stories that ‘suicide is not a solution’ (Editor #5, Chennai) and that ‘suicide is not the answer, she could have been alive to fight’ (Senior Reporter 7, Chennai).
Doubts around preventability of suicide
Despite the above suggestions for mass media to play an informative and educative role, several participants held strong doubts that mass media could do much to prevent suicide. Participants articulated that they were ‘not at all sure how media can help prevent suicide’ (Senior Reporter #1, Delhi). It was also reflected that suicide is intertwined with broader and complex socioeconomic issues that exacerbate people’s mental pressures, leaving media and others with little they can do to help prevent suicide. As explained by one senior crime reporter:
Media cannot prevent any crime or suicide. We can raise the issue, even police cannot stop. If I have decided to suicide, what can media or police do? If I am committing suicide in my own room, what is police going to do? It is about how can you make people mentally strong. Something is lacking in the city. Lack of literacy, poverty, such things. People are not in such place they can come out of that pressure. It is not like anyone can prevent some kind of suicide. (Senior Reporter #2, Delhi)
Other participants highlighted that there are additional challenges to suicide prevention in India posed by an under-resourced mental health sector and pervasive mental health stigma that impedes help seeking. ‘Mental health services are very bad’ (Senior Reporter #7, Chennai) and it would be unreasonable to expect media to be able to resolve these issues. As articulated by one health editor:
people think that going to a psychiatrist means you are insane or mad, people will look down upon you, so they don’t visit the psychiatrist… it’s a major problem for preventing suicide in India. So, prevention of suicide, with all these issues, I would be very apprehensive about how you prevent suicide in India and how media even can truly prevent a suicide. (Editor #1, Chandigarh)
Media reporting and imitation suicide
The second major thematic area was perspectives and experiences in relation to the effects media reporting of suicide events may have on stimulating imitation suicides. It was a predetermined area of interest in the discussion guide, given that the primary interest in media’s role in suicide prevention has historically been based around concerns regarding the effect of media reports on imitation suicides. Three main subthemes emerged.
Concerns regarding the risk of imitation suicides
Many participants expressed serious concerns around the impact of media reports of suicide events on vulnerable readers, highlighting that media reports may normalise suicide as an option: ‘we are afraid of copycat suicide deaths’ (Reporter #1, Chennai), ‘I know that readers may normalise suicide’ [Editor #4, Delhi] and ‘I think it’s pretty common sense that vulnerable people reading about suicides are going to be affected… it might plant an idea that suicide is an answer to their problems’. (Reporter #4, Chennai).
One senior crime reporter reflected that the suicide reports published by their media colleagues may inadvertently have negative effects: ‘When a person is having suicidal tendencies I think it is very easy to influence them in a particular direction so they might get influenced by reading a simple media report that a reporter might have written… without realising that someone may get ideas from’ (Senior reporter #4, Delhi).
Participants also reflected on their worries about the negative impact of their own suicide reporting and their lack of training in this area: ‘When we write suicides, I am worrying if we are contributing to this. Those who are vulnerable, emotional in nature… such news has a serious impact on them. It may be a small part of the population, but media do not think about the impact on them’ (Senior reporter #9, Chennai) and ‘the first time I wrote about a 15-year-old student committing suicide because of doing bad in exams, I felt bad about any other student who might read the story, so I don’t like writing these stories… I don’t have any training about how to write such suicide stories.’ (Reporter #4, Chennai). Participants also expressed that they sometimes felt fearful of publishing particular suicide news: ‘with student suicides, we sometimes fear that if we telecast a student suicide it may trigger more student suicides’ (Senior Reporter #13, Chennai).
Participants also clarified that while they have concerns about imitation suicides, media reports could not be blamed as the main reason for any particular suicide. Media reports were perceived to be a background factor, rather than a main reason for a suicide. One bureau chief explains:
If someone is depressed and already thinking of suicide and he goes through stories of suicide, then that risk may be there for him. But usually, I think it’s not the main cause, but if someone is depressed and already thinking of committing suicide, these stories may become a trigger for them. If a lot of stories are coming and they go through three or four suicide cases every day, then they may try to imitate that. (Bureau Chief #1, Delhi).
Another bureau chief highlighted the importance of identification in the process of imitation suicides through the media, and the audience may also be attracted to the level of media attention given to suicides. ‘There are many people struggling with the same issues faced by people who have died by suicide, so a reader may identify with them, you know, it seems close to their situation… they may also see the public profile that this case gains and wonder how the public will react if they suicide as well.’ (Bureau Chief #4, Chennai)
Instances of perceived imitation suicide events
While details of specific imitation suicides were not sought during the interviews, several participants voluntarily offered clear examples of instances that they perceived to be imitation suicide events that were connected to media coverage. Participants described how ‘soon after we report a suicide, we see 4 or 5 other suicides that seem to follow the case reported in the story… we see people go to the same location and do the same thing.’ (Senior Reporter #9, Chennai).
A wide variety of examples were provided of imitation suicides as well as the dissemination of suicide methods and suicide locations. One health editor identified the impact of media reports of a suicide connected to a celebrity and the ensuing increase in suicides at the same location:
In Chennai we have [a well-known] bridge over a river. A leading singer’s husband committed suicide there, and it was big news. After he committed suicide, everybody is going and jumping. People asked for a barrier to be put up. It has become a suicide point that people know about. (Editor #4, Chennai).
A senior health reporter discussed further examples of particular detailed suicide methods and locations being provided in media reports, resulting in suspected imitation suicides:
Somebody climbed up to the top floor of a mall in Chennai and jumped from an open window and committed suicide. The newspapers carried the story, detailing how this man went up the mall and which window he jumped off. So, in less than a month after that, one more person took the same route, went up, jumped off the same window. After which [they] put up those nets and blocked access to the top floor. Metro suicides in Delhi also give a lot of ideas to people. So, if metro suicides are curbed in reporting, or suppressed as information, then I can guarantee it will have an impact in Delhi. (Senior Reporter #5, Delhi)
While participants gave examples of suicide methods being disseminated through media reports, they also stated that novel suicide methods were highly newsworthy. One bureau chief explains:
Jumping in front of the metro trains, that is something I think people are picking up from the media, there is one or two every month. But, if there’s a unique method, like falling in front of a metro train, then you have to write that information, how can you ignore that? The novelty is the method. Newsworthy is the main thing for us. (Bureau Chief # 2, Delhi)
One bureau chief explained that while they could recall several instances that they perceived were imitation suicide events, it is hard to be certain that the suicides are related to the media coverage:
A man set himself on fire. He was complaining of high interest rates by money lenders. That led to a spate of copycat suicides, for sure. Also, someone jumped off the railing in a shopping mall, and for a few weeks after that there were some jumpers. Also, some kids jumped into a well and committed suicide, and then you had people jumping into the wells… We don’t know for sure [if it is imitation suicide], but it’s more than a coincidence if there are four or five self-immolation deaths after a very high-profile incident using the same suicide method. (Bureau Chief #4, Chennai)
Dismissal or minimisation of the role of media in imitation suicide
In contrast to the above-mentioned perspectives, a minority of participants held views that dismissed or minimised the potential for media reports to be implicated in imitation suicide events. Some media professionals expressed scepticism, arguing that any such instances would be rare, and that some people may even be put off suicide from reading some types of suicide reports. One crime reporter stated:
I think [the number of] people drawing inspiration to suicide from a news article is very miniscule, if you look at it. Alternatively, a person might just read an article and there’s a chance they might find inspiration that I shouldn’t be doing this to myself and if I do this then my family will be depressed if I die… I shouldn’t follow this person’s example (Senior Reporter #4, Delhi)
Others minimised the impact that news media might have on imitation suicides, while arguing that fictional media is the real problem: ‘news channels have a limited impact on viewers, while TV series and films may have a bigger impact’ (Senior Reporter #8, Chennai) and ‘people are not copying what is published in the newspaper, but they are taking ideas from TV series’ (Senior Reporter #2, Delhi).
Several participants raised concerns around attributing any particular suicide to the effects of viewing a media item: ‘to attribute it to a media story is not that appropriate; I have got lakhs (1 00 000s) of readers and not everyone has gone and committed suicide. (Bureau Chief #2, Delhi). Some participants also argued that reporting suicide methods in the media is unlikely to have a major effect on the public 'given it is the Google world and people can find suicide methods online’ (Senior Reporter #1, Delhi) and that ‘it’s unlikely people would go to a news report and try the suicide method’ (Senior Reporter #3). Others made the argument that ‘there is no such case of imitation suicide here [in Chennai] that followed a media report; we get all the information on suicides so we [crime reporters] would know’ (Editor #7, Chennai).
Publishing contact details for suicide helplines
The third major thematic area was in relation to publishing the contact details for suicide helplines. It was a predetermined area of interest in the discussion guide, given that a core feature of international media guidelines is encouragement to provide contact details for suicide helplines in media reports related to suicide. Several participants identified this as a strategy that needs to be given closer consideration and scrutiny in the Indian context. Three main subthemes emerged.
Poor awareness and utilisation of suicide helplines
A small number of participants were confident in regularly publishing helpline details, saying that ‘it should be helpful to promote helplines, that goes without saying’ (Editor #3, Delhi) and that ‘the suicide helplines are fantastic, they are doing a very good service and it works in some cases… media can mention the helplines’. (Senior Reporter #7, Chennai). However, most participants stated that ‘the level of understanding of helplines is low and most people [in the population] are not aware of them’ (Editor #6, Chennai) and that ‘helpline people say they don’t get any calls’ (Editor #1, Chandigarh). In part, this was explained by a sense that ‘media hasn’t done much to put out information about where suicidal people can go to get help’ (Senior Reporter #8, Chennai). Some participants stated that even if they ‘do sometimes mention the helplines, not many people call them’ (Senior Reporter #4, Delhi).
Concerns regarding the quality and effectiveness of suicide helplines
Many participants expressed a level of reluctance to publish the suicide helpline numbers in their media reports, raising concerns around quality and effectiveness. Participant expressed confusion around the helpline model and how such services work in practice. There was a sense that ‘we don’t know whether they actually work’ (Senior Reporter #8, Chennai) and doubts were raised that ‘if someone has decided deep inside his or her mind that he will suicide, how does a helpline or anyone else prevent it’ (Senior Reporter #1). Some participants were wondering why you might give a helpline number instead of simply encouraging people to go directly to a mental health professional: ‘We don’t understand how it works and I’m not very comfortable with the idea of a helpline… how do you prevent suicide with the helpline? I would rather directly give the number of a doctor or psychiatrist’ (Editor #1, Chandigarh). Concerns were also raised that giving helpline details in media reports is unlikely to reach suicidal people experiencing poverty and disenfranchisement, as explained by one senior crime reporter:
in most cases helplines don’t work. We have many crores (millions) population and nobody cares what someone does. We have more than 30% unreachable population, which you cannot reach by media. They are downtrodden people, under the poverty line. (Senior Reporter #7, Chennai)
The second issue related to important concerns was raised by participants as to the quality of suicide helplines and a lack of evidence of effectiveness. As explained by one senior health reporter, ‘the problem is the quality of these services… if you launch a service the numbers [of suicides] should come down… if the numbers are not coming down, it isn’t working’ (Senior Reporter #1). One editor commented that a government medical college had set up a 24/7 helpline, but ‘because it is a government set-up I think the bell will keep on ringing and no one will pick up the phone… even if they might be available, they say they’re not available. Helpline is a joke’(Editor #1, Chandigarh). Others similarly raised concerns that if people ring the helplines in a time of crisis, the staff may not pick up:
One suicidal boy found a suicide helpline number on Google and called them at night. No one picked up. Finally, one doctor took a call from the boy had a conversation with the boy and consoled him, and it prevented him from suicide. The helpline must be 24/7. It isn’t a helpline if it is only 9–5. People may commit suicide at any time [of day]. (Editor #6, Chennai)
Barriers to regularly publishing details of suicide helplines
Some participants highlighted that Indian media practices acted as a barrier to the possibility of regularly naming helplines in media reports related to suicide. As explained by one bureau chief:
It is a good thing to have a helpline but in the Indian media we tend not to put the same thing again and again. Advisories, like don’t smoke or don’t drink, can’t be published in every article. Like call this helpline, call this helpline, every day, it becomes too much like an advertisement. Even if it’s a government service, we can do it once, we can’t do it week after week (Bureau Chief #2, Delhi).
This issue was compounded in the case of helplines run by nongovernmental organisations, some of whom were not considered to be trustworthy. One senior crime reporter explained this attitude:
NGOs are doing PR. They are not working properly, and we can’t trust that if we give this phone line it is going to be beneficial for people. It needs to be a trust-worthy body. Some NGOs are doing very good work, but most NGOs are doing things for the money (Senior Reporter #2).
Media guidelines and self-regulatory practice
The fourth major thematic area was around awareness of, and receptiveness to, media guidelines on suicide reporting and experiences around self-regulatory practices in the absence of Indian media guidelines. Three subthemes emerged.
Awareness of existing international guidelines
The majority of participants expressed that ‘there are no guidelines, there is no rulebook’ (Senior Reporter #12, Chennai) and that they were unaware of any national or international guidance or recommendations on media reporting of suicide. As expressed by one bureau chief: ‘I haven’t come across any study that says how we should report on suicide… I have not come across any such training or guidelines’ (Bureau Chief #1, Delhi). When asked by the interviewer whether they were aware of international media guidelines published by the WHO, almost all participants had not heard of them and they also reflected that the media organisations they worked for had not raised any guidelines to their attention: ‘You say there is a World Health Organization guideline around media reporting of suicide, but none of the media companies I’ve worked for bothered to look at the guidelines and train editors and reporters in this’ (Reporter #4, Chennai).
Receptiveness to Indian media guidelines
Participants were asked whether media professionals in India need more information or guidance on reporting of suicide-related news, in so far as it might help them to support the goal of suicide prevention. It was broadly acknowledged by all participants that ‘there are no media houses who want to encourage people to commit suicide’ (Reporter #1, Chennai). Consequently, all participants also expressed that ‘there would be value in having guidelines’ (Editor #3, Delhi) that would provide recommendations. As explained by one senior crime reporter: ‘Definitely there should some guidelines… avoiding going into details about the suicide method, minimise attention to public locations, avoid harassment of family’ (Senior Reporter #3, Delhi).
Many participants drew on prior examples of media guideline development in India, to provide encouragement that guidelines for suicide reporting could be developed and implemented successfully over time. A commonly offered example was the development and implementation of Press Council of India media guidelines for reporting related to HIV/AIDS. As explained by on senior reporter:
A few years ago the government did a major HIV campaign, to spread awareness about preventing HIV and reducing stigma… they should definitely do more to spread awareness about suicide prevention, as many more people die by suicide than AIDS. We need media guidelines. Just as we have for reporting on patients suffering from AIDS. We don’t show their photo or identify them in any fashion. We speak of them in a non-judgemental fashion. Similar things need to be followed when reporting on suicide. People need to be made aware that these are people who need help. Don’t put them down, don’t judge them. Get them help. (Senior Reporter #8, Chennai)
Participants felt that the HIV/AIDS guidelines have resulted in a ‘vast difference in reporting compared to 20 years ago, the language of accusation has changed… it took many organisations, resources, huge money and persuasion over a long time, but it did happen… to change the language around suicide needs time’ (Senior Reporter #1, Chennai).
Another encouraging example was provided in relation to organ donations, with multiple stakeholders coming together to improve public understanding and attitudes through reporting in the mass media. As explained by one health editor:
In 2008, when we started reporting about organ donations, because of a series of health department orders… The number of people who donate organs zoomed and today we are a leading country in organ donations. We will be able to do it with suicide and reporting guidelines as well. (Editor #4, Chennai)
Current self-regulatory practices
In the absence of Indian-specific media guidelines and a lack of awareness of existing international guidelines, several participants reported that ‘most media here take self-regulating decisions’ (Editor #4, Chennai), either occasionally or regularly, and that ‘we try to follow our own guidelines, informally’ (Senior Reporter #3, Delhi). One bureau chief articulated how their newspaper had gone against the dominant trend to change their approach to reporting on suicide over the past 5 years:
It has to enter your consciousness that suicides lead to copycat suicides and reporting them can have a deleterious effect on the society itself. When you are ready to imbibe that kind of input, then you are ready to make changes… It’s ultimately about how it is being reported. We provide some information on counselling and other services. We try to write about it sensitively, because the temptation is to be graphic for maximum impact, but I think a certain amount of sensitivity at this stage, when you are dealing with suicides, even high-profile suicides, is important. (Bureau Chief #4, Chennai)
Some participants described experiences where their organisations had independently taken some steps to temper the high frequency of graphic suicide coverage for fear of ‘triggering the suicide mentality by reporting too many suicide stories’ (Editor #5, Chennai), and others articulated that their editorial policy is that they now only report on suicides where ‘there is something interesting that we can convey’ (Editor #4, Chennai). Participants identified that there is a business model pressure to regularly report suicide news in a sensational fashion, although this assumption has not properly been tested. As explained by one bureau chief:
We keep the suicides that happen for ostensibly personal reasons out of the newspaper, unless it happens in a public place, like someone falls off a building, or someone dies in a school or a college, or the suicide note blames someone in a public post. Otherwise, we tend to now look the other way. There are a lot of suicides and what do we gain by reporting this? A lot of this breast beating, “I give you the news first”, kind of thing, doesn’t come from solid business sense. It comes from a very mindless perspective. Unfortunately, there is no scientific measure as to what makes better business sense. I can only say we haven’t lost readership from following this practice. I think it’s a call that every organisation will have to take. (Bureau Chief #4, Chennai)
Participants also described avoiding reporting on the detail around suicide methods, including novel suicide methods, to avoid giving people information as to how they can kill themselves: ‘if a poisoning, we don’t mention the poison, in case someone else is planning a suicide and he might go out and find the poison’ (Senior Reporter #3, Delhi) and ‘if you give the method then you might just be giving the idea about the methods of how to kill yourself to someone who is depressed.’ (Senior Reporter #4, Delhi). Others articulated that their approach was to avoid this detail on suicide methods by focusing more on the broader socioeconomic and political issues that may be related to the suicide. Giving the example of farmer suicides, a senior crime reporter stated that:
we try to report farmer suicides in such a manner so that more suicides do not take place… instead of talking about how he committed suicide… we highlight the plight of farmers more broadly. For example, a farmer may suicide by self-immolation, and some media will sesnsationalise this act. We choose to focus on the social and economic issues and the political drama. (Senior Reporter #11, Chennai)
Some participants discussed student examinations as a high-risk period for suicide, which saw them adjusting their media coverage with the goal of helping to prevent suicide. One crime reporter stated that during the examination period:
we put the suicide helpline number and take advice from experts in suicide prevention. We bring psychologists and psychiatrists into the studio and interview them, as well as government policy people to clarify any system issues, so that people don’t think they need to commit suicide over this. (Reporter #3, Chennai)
Others highlighted that they will sometimes use ‘a small box that gives prevention messages, like please consult a doctor’ (Buruea Chief #2, Delhi) or provide messages saying ‘don’t do it… there’s a way to prevent it’ (Reporter #1, Chennai).
Development and implementation of Indian-specific guidelines
The fifth major thematic area was the perspectives of media professionals as to how Indian-specific guidelines could be developed and implemented. Four subthemes were emerged.
Development of voluntary guidelines
Participants discussed the need for Indian-specific guidelines that are suitable for the Indian context, ‘you simply can’t compare with other countries… there are a lot of differences, community-wise, culturally, politically and in terms of the intersection between suicide and social injustices… sometimes our suicide reporting can create social change’ (Editor #5, Chennai).
To develop Indian-specific guidelines, it was commonly suggested that it needs broad participation across the media sector and input from a range of stakeholders. ‘All major media houses should get together and fix a guideline’ (Bureau Chief #2) and that ‘we need mental health experts, media experts and media houses, the police and maybe the law commission to get together and draw up a draft’ (Senior Reporter #9, Chennai). Others highlighted the key role of higher level authorities, as articulated by one editor:
We have the Press Council of India. Maybe if they take the initiative and circulate some guidelines. Maybe if the government, the health ministry, invites these bodies, the press clubs, the press association, hold a brainstorming, and emerge with two or three guidelines, simple ones, but you know, it has to be organised, … it has to have a government participation… If the big players do it, it can happen. It must have a government role in it somewhere, because that draws in the media players. (Editor #2, Delhi)
It was repeatedly stressed by almost all participants that any such guidelines ‘have to be voluntary… there can’t be a total blackout of suicides in media coverage, but it can be toned down’ (Editor #2, Delhi). Participants stated that ‘you can’t stop the media from reporting on suicides, nor can you decide the way guidelines will be used, that’s the editor’s prerogative… but, you can give a guideline saying that when you’re reporting on suicides please do it in such a manner that the public is educated’ (Bureau Chief #2, Delhi).
Some participants expanded the stakeholders to be involved to include police, given their integral role in providing crime reporters with ready access to details for suicides across the country. Police input could be helpful with respect guidance around reporting while the relevant investigations are incomplete. One editor argued that police should be ‘slower at releasing the information to the media, and once you get through that initial phase media will have moved on to something else… half of the detail of suicide is gone if police say they are not commenting on incidents suspected to be suicide until further investigations have taken place’ (Editor #2, Delhi).
All participants were clear in highlighting that guidelines alone would not be enough. The phrase ‘sensitisation’ was commonly used to articulate an important next step after the development of guidelines, with training and other sensitisation approaches required for media professionals in relation to any new guidelines ‘so we are more conscious’ (Bureau Chief #1, Delhi). ‘The sensitisation process is critical, you cannot expect the journalists to be aware of all the sensitivities’ (Senior Reporter #9, Chennai) and ‘there would be value in having guidelines, if people were to read them… we need sensitisation, some explanation as to why these guidelines are important’ (Editor #3, Delhi).
Others articulated more specifically that ‘face-to-face training and media workshops are best, otherwise they will not go through an online course [and that] you can also integrate into the curriculum for new graduates’ (Bureau Chief #1, Delhi). It was highlighted that this training should be provided for reporters and the broader range of personnel involved in the production of a suicide-related media report (eg, photographers, people writing headlines, etc).
Most participants stressed that ‘simultaneously you need to educate editors also’ (Bureau Chief #1, Delhi), because ‘at the end of the day I’m reporting to my editor in my office, that’s who I’m answerable to’ (Reporter #4, Chennai). The editorial team were viewed as ‘the guys that stand between the crime reporters and the public’ (Bureau Chief #4, Chennai) and that even if field reporters ‘know something about what we should or shouldn’t say in a report, our news desk don’t understand such things… news is group work’ (Senior Reporter #13, Chennai). Otherwise, ‘if your editor comes to us and asks us to run a suicide story, obviously we are going to say yes because we don’t want to give them a lecture on media reporting around suicide’ (Reporter #4, Chennai).
Finally, participants felt that suicide prevention experts and organisations need to engage with the media owners and the highest levels of media organisations. As explained by one senior reporter:
My point of view is that suicide prevention organisations should have interaction with the media on a periodical manner… the interactions need to happen at the higher levels of the media organization, and then the media desk will handle it in a different manner and will follow the directions that are given. (Senior Reporter #8, Chennai)
This approach was seen as crucial, so that ‘we can get media owners and editors to give a strict circular that our newspaper will follow the guidelines… reporters are small pawns in this whole thing’ (Reporter #4, Chennai).
Embedding guidelines in style sheets and templates
Another strategy that was viewed by participants as being critically important was to integrate guidelines into style sheets and templates that largely guide the approach to reporting on suicide. As explained by one health editor:
I want these guidelines to get into style sheets, the rules of the syntax for the newspaper. There is no point in just having guidelines for health reporters. Everyone who is working the story and they are on the same page. Even the kind of illustrations that go into a suicide story are terrible. These changes should get into style sheets of newspapers. (Editor #4, Chennai)
One participant gave the example of how their organisation changed the template for reporting on suicide so that the last line gives details for suicide support services:
Template would be number one. It doesn’t cost you anything, no time, no energy. Templatising also makes it routine. Having a template works. For example, we now mention counselling services at the end of each article. The last line in every report is, call this number. It’s just a line, it’s doable. (Bureau Chief #4, Chennai)
Compliance issues with voluntary guidelines
Almost all participants raised the prospect that there might be poor compliance with voluntary guidelines, highlighting the need for some form of ongoing follow-up. Some participants argued that ‘we need guidelines and tools with some force behind them… in India we have some laws, but people don’t follow them, and we need someone there to tell them not to do something’ (Editor #6, Chennai). As explained by one senior reporter:
You can have guidelines, but who follows the guidelines. In the evening I’m reporting, do I have to read the guidelines? Then I will not make my deadline. Guidelines are always good, but I don’t know how regularly they’re followed. It’s the problem with all guidelines… Once the guideline is made there is no follow-up made to check whether the guidelines are being followed or not. The follow-up is essential. (Senior Reporter #1, Delhi)
In contrast to the dominant suggestion for voluntary guidelines, some participants went further to suggest that ‘media guidelines have to be enforced, it’s not enough to just have guidelines’ (Senior Reporter #8, Chennai). Suggestions were made to make certain aspects of the guidelines mandatory, ‘make it mandatory to publish a helpline, and have a box saying how suicide can be prevented’ (Bureau Chief #2, Chennai). Others suggested that ‘it’s important to involve the police and the Supreme Court, the law makers in the country, it has to be enforced.’ (Senior Reporter #5, Delhi). For example, ‘if a Supreme Court orders that we don’t publish the location of a suicide death, we will have to follow’ (Senior Reporter #2, Delhi).
We sought to examine the perspectives and experiences of media professionals in India in relation to suicide reporting. We previously reported our findings regarding the newsworthiness of suicide and the processes and challenges involved in covering suicide news.24 In this paper, we present media professionals perspectives in relation to media’s role in suicide prevention, their recommendations and challenges related to the development and implementation of media guidelines for suicide reporting in India, their beliefs and experiences regarding imitation suicide events and their attitudes in relation to providing contact details for suicide prevention services.
Strengths and limitations
We adopted a rigorous and systematic approach to this study. One author conducted and transcribed all interviews, two authors independently undertook coding, and all authors contributed to the final coding frame and interpretation of data. The deductive and inductive approach to thematic analysis allowed for both a comprehensive focus on some key areas of enquiry and the emergence of a wide range of subthemes. The sample included 28 media professionals from two major cities and one smaller city across print, TV and online news media. One-quarter of participants were operating at an editorial level and four were bureau chiefs who held high-level knowledge of reporting practices at their media houses. Nonetheless, there were some limitations. Our findings may not reflect the situation outside of Delhi and Chennai, including nonurban settings. Participants self-selected into the study, which impacts the generalisability of the findings; those with a special or passionate interest in this issue may have been more likely to offer their participation and we may have missed the perspectives of those media professionals who are more disinterested in the issue. The interviews were largely conducted in English rather than in participants’ first languages, which may have impacted on the quality of the data. Finally, social desirability bias may have influenced the responses of some media professionals, who may have been willing to indicate receptiveness to hypothetical media guidelines in a face-to-face interview with a suicide prevention expert but who may nonetheless resist such guidelines if they were implemented in practice.
Role for media in suicide prevention
A clear role for media in suicide prevention was articulated by several media professionals, based primarily around informing and educating the public rather than the current practice of rapid suicide reporting dominated by brief, graphic and sensational coverage of specific suicide deaths and attempts. This demonstrated a clear level of willingness among some participants towards changing media practices and openness to conversations around how this change can best be guided and facilitated. Nonetheless, a fatalistic attitude towards suicide was evident among several health and crime media professionals in this study, with the view that there is little media (and others) can do to prevent suicide and that mental health services in India are under-resourced and help seeking is low. The doubts raised by these participants are important to engage with, but it is nonetheless a profound concern if fatalistic attitudes filter through their reporting to influence the public’s attitudes towards the preventability of suicide. Debunking suicide myths, such as there is nothing you can do to prevent suicide, is an important and common strategy adopted in suicide prevention education.35 36 Our findings strongly indicate that engagement with media professionals in India around responsible suicide reporting ought to be accompanied by broader suicide prevention education to allow any personal doubts and misbeliefs to be ventilated and responded to and to support their reporting to directly challenge suicide myths. It may not only be media professionals who would benefit from this, while we have focused our research on media professionals, it is important to highlight that evidence from elsewhere in the world suggests that mental health professionals themselves may also hold heterogeneous subjective positions on the role of media in suicide prevention.37 This could be examined and addressed in India as it will be important to develop consensus and support across both the mental health and media sectors.
Concerns around imitation suicides
Imitation suicides are a prime concern in relation to media reporting of suicide, with research highlighting the potential for media reporting to impact population suicide rates in both harmful and protective ways.10 38 The majority of evidence comes from outside India in high-income countries, although a recent study in India has captured the large and concerning impact of a reported high-profile celebrity suicide on suicide-related internet search behaviours in the population.39 A majority of participants in our study acknowledged the possibility that their reporting may negatively influence vulnerable people in the population and lead to imitation suicides. Several participants also provided anecdotal accounts of specific instances that they perceived to be imitation suicide events stemming from media reporting. For example, some participants suggested a curb on graphic reporting of metro suicides in an effort to reduce the perceived growth in this suicide method, which would align with international evidence from Austria where the high incidence of subway suicides reduced after the introduction of media guidelines.40 That media professionals in India are readily forthcoming with such constructive and indeed evidence-concordant suggestions raise the query as to what is preventing action from taking place. A repeated point made by reporters was that they had little power or autonomy in the process of deciding how suicide-related news is covered, indicating a strong need for engagement at the highest levels of media organisations.
A minority of media professionals dismissed or minimised concerns around imitation suicides, and others raised legitimate queries as to whether the harmful effects of graphic suicide scenes in fictional media were likely to be of greater concern than those presented in nonfictional media. The suicide content in fictional media and its effects on viewers have recently received a high level of attention in the USA, with the release of the TV series 13 Reasons Why associated with an increase in suicides in the population.41 The WHO has also released guidelines for filmmakers and others around portraying suicide in visual media.42 However, this phenomenon remains underexamined in India, where suicide is a common theme in films and TV series with narratives that have a strong cultural resonance.43 44 Future research in India should broaden out from its focus on nonfictional media to also engage with the issue of suicide content in fictional media. Research may also examine the impact of suicide content on social media,45 which is also largely unexamined in India.
Publishing details for suicide helplines
Media professionals expressed hesitance to publish the contact details for suicide helplines on a regular basis. A wide range of state and national helplines are available across India, from the longstanding Chennai-based SNEHA suicide prevention helpline (founded by author LV) to the recently launched nation-wide KIRAN mental health helpline, and the quality and systems surrounding each will inevitably vary as each service evolves. We should not too quickly dismiss what are genuine concerns from media professionals around the programme theory and efficacy of helplines. To address any misunderstandings, suicide prevention experts should seek to provide media professionals with a clear rationale for the helpline model and an explanation as to how they operate, perhaps including onsite tours with clear examples given of the processes involved and accounts from people with lived experience of using helplines for support during a suicide crisis. Local research evidence on the proximal and distal effects of helplines46 may also help provide confidence to media professionals in giving the helpline information to the public.
Media guidelines and engagement strategies
We found that media professionals in India were largely unaware of neither WHO guidelines nor any other media guidelines for suicide reporting, which is consistent with our previous research revealing that media reporting of suicide in India was largely nonadherent to recommended reporting practices.19 Nonetheless, some form of self-regulatory practices were reported, including some rare instances of high-level decisions being taken by some organisations to dramatically reduce the sensational nature of their suicide coverage, indicating an instinctive yet unguided understanding that some form of regulation or caution is required.
Media professionals were largely very receptive to the idea of developing voluntary guidelines for the Indian context, although some participants expressed concerns that there would be compliance issues. International literature has strongly indicated a preference for voluntary rather than mandatory/enforced guidelines,29 30 yet it is worth taking heed of the perspectives of those operating in the Indian context who say that people would not follow voluntary guidelines. Several participants offered a reassuring reminder that voluntary changes to media reporting practices were able to be implemented in India in relation to reporting around HIV/AIDS over the past 10–15 years, after a very well-resourced and sustained engagement with media. Nonetheless, we have previously highlighted the intense systemic pressures to report graphically and sensationally on ‘newsworthy’ suicide events,24 and these systemic issues need to be addressed using a strong collaborative approach rather than a top-down guideline in isolation. Evidence from elsewhere in the world also highlights the challenges in implementing media guidelines, with some media professionals resisting being told how to write their news stories.30
Innovative approaches to engagement and sensitisation need to be trialled in India. For example, the recently launched Project SIREN initiative (led by author SP) has media professionals training their peers, and they use a ranking approach to encourage a competitive improvement in observance with recommended reporting practices.47 Other useful suggestions were raised, such as embedding guideline-based training into journalism colleges and integrating changes into style sheets and reporting templates (eg, ensuring a helpline is mentioned in the report) so as to improve the consistency of improved reporting practices. Evaluations of training programmes on suicide reporting from elsewhere in the world offer encouragement that training can have multifaceted positive effects, improving knowledge, awareness and reporting styles, while also reducing misconceptions and insecurities associated with responsible media reporting.48 49 In all the above-mentioned approaches to engaging media professionals, the emerging breed of health journalists in India will be critical allies.
It is also worth reflecting that the WHO guidelines, while based on a considerable amount of international evidence and inputs from people across several countries, have nonetheless been written for a global rather than a local audience. Being an international standard, they have necessarily been developed in somewhat of a culture and context vacuum, so that they are of broader utility. However, our prior research has highlighted how suicide reporting in India is intimately intertwined with sociocultural frameworks.24 Our current paper also reveals a range of attitudes and systematic reporting issues, such as a reluctance to consistently report details for helplines (or other ‘health advisories’), that need to be addressed through guidelines developed for the Indian context. Our findings indicate a clear need for guidelines to be developed that are situated in the Indian context and that have a strong basis in high-quality research evidence, with a priority for integrating research evidence and reporting examples from within India and the South Asian region. It may be that most core recommendations (eg, avoiding giving details of suicide methods) are largely unchanged, but that they are positioned and communicated within an understanding of the Indian cultural and media practice context.
In order to support the development of adapted country-specific guidelines, it is essential to examine the richness of the perspectives and experiences of media professionals operating in their country context. This conclusion would be equally relevant to other country contexts that are yet to engage in a systematic way with this issue. Our findings delve into the complexity of reporting on suicide in India and can be used to support constructive partnerships between media professionals and suicide prevention experts. To change reporting practices, guidelines will be insufficient on their own, with a clear need for a genuine and sustained partnership between suicide prevention experts and media professionals at all levels. Further research is needed in India to examine the impact of media engagement initiatives on reporting and suicidal behaviour outcomes.
Data availability statement
Data may be obtained from a third party and are not publicly available. All data relevant to the study are included in the article. Raw data cannot be shared publicly due to ethical restrictions. Requests for access to the raw data can be sent to the Human Research Ethics Committee at The University of Melbourne (HREC 1749532.1) at the following email address: HumanEthics-Enquiries@unimelb.edu.au.
Ethics approval was provided in Australia by the Human Research Ethics Committee at The University of Melbourne (HREC 1749532.1). Ethics approval was provided in India by the Institutional Ethics Committee of the Schizophrenia Research Foundation (SCARF) in Chennai. SCARF is a WHO Collaborating Centre for Mental Health Research & Training.
We sincerely thank all the study participants and Ms Sandhya Ravishankar who supported the recruitment of participants alongside Mr Kannan Krishnaswamy.
Twitter @googarmstrong, @netshrink
Contributors GA, LV and KK designed the study, collected the data and wrote the first draft of the manuscript. KK supported data collection and brought expertise as a veteran media professional. Analysis was undertaken by GA and AC with support from LV, SP and KK. All authors read and improved the final manuscript and assisted in interpreting the findings.
Funding The lead author is funded by an Early Career Fellowship from the National Health and Medical Research Council in Australia (GNT1138096) and Early Career Researcher Awards from The Society for Mental Health Research and The University of Melbourne.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.