The pattern of suicide in Pakistan

"I didn't do it!": Lived experiences of suicide attempts made without perceived intent or volition

Suicide is considered to be a conscious and intentional act that is carried out within a social and cultural context. This study examines the unique phenomenon of a cluster of suicide attempts conducted without perceived intent, ideation, plan, volition, or agency in a remote province in Central Asia. This study investigated the lived experiences of individuals who made such unintended suicide attempts and examined the differences between these experiences and those of individuals who made their suicide attempt with intent and agency. The authors conducted a secondary analysis of qualitative data originally collected for a prior grounded theory study. The present study examined a specific and unique set of participant experiences related to suicide attempts made without agency. Results found that instances of suicide attempts made without perceived intent by participants included themes of impulsivity, not knowing what happened, feeling out of control, attributing these experiences to the supernatural, and being fearful of such events occurring again. Clinical practice may need to be adapted to address experiences of such unique suicide attempt experiences. In addition, further research is warranted to understand and examine the phenomenon of suicide attempts carried out without perceived intent, ideation, plan, volition, or agency.

Sociodemographic Characteristics and Patterns of Suicide in Pakistan: An Analysis of Current Trends

Suicide is a global phenomenon with about 79% of suicides occurring in low and middle-income countries. This study investigated current trends, demographics, and characteristics of completed suicides based on reports from leading Pakistani Newspapers. This study performed a qualitative analysis of completed suicides in Pakistan's four newspapers from January 1st, 2019, through December 31st, 2020. Data about socio-demographic characteristics, methods of suicide, possible motives, and associated features were analyzed. 2295 suicides were reported in Pakistan during 2019 and 2020. About 61.87% were completed by men, and 38.12% by women. The most suicides occurred in individuals ages < 30 years. The predominant method of suicide in this group was ingestion of poisonous substances. The most commonly reported reasons for suicide were domestic conflicts, financial problems, and failure in love/marriage. By providing insight into characteristics of suicide, this study highlights the need for effective suicide prevention policies and programs to tackle rising rates of suicide in Pakistan.

Psychological strain and suicidal ideation in young university students during Covid-19 outbreak: the mediating roles of rumination and depression

The link between psychological strain and suicidal ideation is well embedded in literature, however, the underlying mechanism is rarely explored. Therefore, this study aimed to examine the relationship between psychological strain, suicidal ideation, rumination, and depression among Pakistani young adults during the Covid-19 outbreak. In addition, it will also try to determine the mediating role of ruminative subtypes and depression in the relationship between psychological strain and suicidal ideation. The sample consists of 400 university students (83 males and 289 females) with the age range from 18 to 30 years (M = 22.25, SD = 2.40). Psychological strain scale, Suicidal Ideation Scale, Beck Depression Inventory, and Ruminative Response Scale were administered to the participants. Results indicated a significant and positive association between the study variables. Psychological strain positively influenced suicidal ideation both directly, and indirectly via brooding and depression. Both variables were found to be serially mediated by the brooding subtype of rumination and depression and not with the reflective subtype. Strain theory of suicide and response style theory also postulated important insights regarding the association of these variables in young adults, among which, strain is serially related to first brooding and then depression, which is eventually related to suicidal ideation. The present study makes a significant contribution to the literature by providing a unique conceptual and theoretical framework to identify suicide at the ideation level before it proceeds to behavior during this unprecedented time of the pandemic outbreak.

Mapping Institutional Interventions to Mitigate Suicides: A Study of Causes and Prevention

Suicide is an extreme, tragic act and an important subject for social inquiry. It is the rising public health issue prevalent in the Himalayan range of Pakistan. The young and educated population is more prone to suicide instead of using this prime phase of age productively. Unfortunately, the suicide problem remains unaddressed, the causes remain undefined, solutions are not in the works, and in situations when others play a part in driving someone to commit suicide, no one is being held accountable. This study is aimed at uncovering the root causes of suicide and proposing some preventive measures to mitigate the problem. Our team studied three years’ worth of data (2017–2019) on suicides from the office of Human Rights Commission of Pakistan, Chitral. In addition, we conducted semi-structured interviews of different stakeholders, including family members, neighbors, lawyers, and police personnel. The findings revealed that extended family pressures, the power dynamic between sustainers and dependents, family conflicts, and inheritance cases were the major causes of the domestic violence that preceded suicide attempts. Mental health issues, forced marriages, academic competitions, and flawed litigation processes were also among the leading causes of suicide. Awareness through education and religious sermons, strengthening healthcare organizations, restructuring family systems, establishing police complaint centers, effective prosecution processes, and imparting lifesaving skills have been identified as measures to prevent suicide. This study has theoretical and practical implications, as it adds certain novel variables regarding the causes and solutions of suicide to the existing body of literature and guides public authorities to strengthen institutions to intervene effectively.

Mental health, suicidal ideation, and experience of bullying among university students in Pakistan

This study investigates mental health, access to treatment, suicidality, and bullying among Pakistani university students. Data were collected from a sample of 355 university students in Pakistan. For reference, we compared these data to a sample previously collected from German and Chinese students. Results indicated relatively poorer mental health and access to mental health treatments among the Pakistani sample, including a higher rate of recent suicidal ideation and bullying. Acknowledgment of these issues in Pakistani culture would be a good starting point to work on developing solutions to enhance the overall mental health of Pakistani students.

Risk factors for deliberate self-harm in patients presenting to the emergency departments of Karachi

OBJECTIVE

To determine the risk factors for Deliberate Self-Harm (DSH) in patients presenting to the Emergency Departments (EDs) of three tertiary care hospitals of Karachi, Pakistan.

STUDY DESIGN

Multicentre matched case control study.

PLACE AND DURATION OF STUDY

EDs of the Aga Khan University Hospital, Karachi, Civil Hospital, Karachi and Jinnah Postgraduate Medical Centre, Karachi, from March 2011 to February 2012.

METHODOLOGY

A total of 201 cases and 201 matched controls were taken from three hospitals situated in Karachi. All patients of 16 years and above presenting to the EDs of the hospitals with DSH attempt were invited to participate in the study. Controls were ED patients with complaints other than DSH. A control was matched with case for hospital, gender and age. Two questionnaires were used to collect information on the risk factors of DSH. Conditional Logistic Regression (CLR) was used to assess the association of various risk factors with DSH.

RESULTS

Risk factors of DSH in Karachi included current history of mental disorder (OR = 4.53, 95% CI = 1.59 - 12.92), not sharing problems with someone (OR = 4.67, 95% CI = 2.4 - 9.0), living in rented houses (OR = 2.58, 95% CI = 1.37 - 4.84), Pathan ethnicity (OR = 5.05, 95% CI = 1.01-25.38) followed by others (OR = 3.88, 95% CI = 0.77 - 19.69) and Urdu speaking (OR = 2.71, 95% CI = 0.59 - 12.45). Absence of physical illness in the past month had an inverse association with DSH (OR = 0.17, 95% CI = 0.07 - 0.37).

CONCLUSION

Mental illnesses, low socio-economic status and loneliness were the risk factors of DSH patients presenting to the three EDs of Karachi. Physical illness in the last month was protective against DSH in these patients. Psychiatric evaluation of DSH patients in the ED is important for early diagnosis and management of mental disorders.

Suicidal Behaviors Among Muslim Women

Abstract. Background: The literature on Muslim women's suicidality has been growing. Comprehensive reviews are, however, unavailable, and theory needs development. Aims: This article reviews and integrates theories and findings about Muslim women's suicidality. Method: Two databases (PsycINFO and Web of Science) were searched for publications about Muslim women's suicidality. Results: There is significant variability in Muslim women's patterns of suicidality across Muslim-majority communities and countries. Muslim women represent half to nearly all cases of nonfatal suicidal behavior. According to the official records of Muslim-majority countries, women's suicide mortality is lower than that of men. Community studies, however, show that in some areas, Muslim women have significantly higher suicide rates than Muslim men. Both nonfatal and fatal suicidal behaviors are most common among uneducated and poor rural young women. Muslim women's typical suicide methods vary by locale, and include self-burning, hanging, and poisoning. With regard to contexts and meanings, a recurring female script is that of suicidality as protest against and desperate escape from the oppressive regulation as well as the abuse many women endure within their families and societies. Conclusion: Understanding and preventing Muslim women's suicidality, and the socially sanctioned oppression it is often a response to, require system-level – not just individual-level – analyses and interventions as well as a human rights perspective.

Most common methods of suicide in Eastern Mediterranean Region of WHO: a systematic review and meta-analysis

The aim of this study is to determine the frequency of various methods of suicide in Eastern Mediterranean Region by a systematic review and meta-analysis. All published articles in international database were systematically searched before September 2011. In order to analyze the data we used STATA, ver.10 software. We reported proportions with standard errors (SE) for single studies and pooled estimates for proportions of different suicidal methods based on random model meta-analysis. We included 19 articles in the final analysis. The pooled proportion of hanging, self-immolation, and poisoning were 39.7% (95% CI: 26.8%-52.7%), 17.4% (95% CI: 10%-24.8%), and 20.3% (95% CI: 14%-26.5%) respectively. Self-immolation and poisoning were gender dependent and hanging was country dependent in the meta-regression method. We found out that the 3 most common methods of suicide in EMR are hanging, poisoning, and self-immolation. These methods are estimated to account for 77.4% of all methods of suicide in EMR.

Suicide in the Philippines: time trend analysis (1974-2005) and literature review

BACKGROUND

Suicide prevention is given a low priority in many Western Pacific countries due to competing health problems, stigma and poor understanding of its incidence and aetiology. Little is known about the epidemiology of suicide and suicidal behaviour in the Philippines and although its incidence is reported to be low, there is likely to be under-reporting because of its non-acceptance by the Catholic Church and the associated stigma to the family. This study aims to investigate trends in the incidence of suicide in the Philippines, assess possible underreporting and provide information on the methods used and the reasons for suicide.

METHODS

Data for suicide deaths occurring between 1974 and 2005 were obtained from Philippine Health Statistics. Age- and sex-specific trends were examined graphically. Underreporting was investigated by comparing trends in suicides, accidents and deaths of undetermined intent. To provide a fuller picture of suicide in the Philippines, a comprehensive search for published papers, theses and reports on the epidemiology of suicide in the Philippines was undertaken.

RESULTS

The incidence of suicide in males increased from 0.23 to 3.59 per 100,000 between 1984 and 2005. Similarly, rates rose from 0.12 to 1.09 per 100,000 in females. Amongst females, suicide rates were highest in 15-24 year olds, whilst in males rates were similar in all age groups throughout the study period. The most commonly used methods of suicide were hanging, shooting and organophosphate ingestion. In non-fatal attempts, the most common methods used were ingestion of drugs, specifically isoniazid and paracetamol, or organophosphate ingestion. Family and relationship problems were the most common precipitants. While rates were lower compared to other countries, there is suggestive evidence of underreporting and misclassification to undetermined injury. Recent increases may reflect either true increase or better reporting of suicides.

CONCLUSIONS

While suicide rates are low in the Philippines, increases in incidence and relatively high rates in adolescents and young adults point to the importance of focused suicide prevention programs. Improving data quality and better reporting of suicide deaths is likewise imperative to inform and evaluate prevention strategies.

Differences in reporting of violence and deliberate self harm related injuries to health and police authorities, Rawalpindi, Pakistan

Background

The aim of study was to assess differences in reporting of violence and deliberate self harm (DSH) related injuries to police and emergency department (ED) in an urban town of Pakistan.

Methods/Principal Findings

Study setting was Rawalpindi city of 1.6 million inhabitants. Incidences of violence and DSH related injuries and deaths were estimated from record linkage of police and ED data. These were then compared to reported figures in both datasets. All persons reporting violence and DSH related injury to the police station, the public hospital's ED, or both in Rawalpindi city from July 1, 2007 to June 30, 2008 were included. In Rawalpindi city, 1 016 intentional injury victims reported to police whereas 3 012 reported to ED. Comparing violence related fatality estimates (N = 56, 95% CI: 46–64), police reported 75.0% and ED reported 42.8% of them. Comparing violence related injury estimates (N = 7 990, 95% CI: 7 322–8 565), police reported 12.1% and ED reported 33.2% of them. Comparing DSH related fatality estimates (N = 17, 95% CI: 4–30), police reported 17.7% and ED reported 47.1% of them. Comparing DSH related injury estimates (N = 809, 95% CI: 101–1 516), police reported 0.5% and ED reported 39.9% of them.

Conclusion

In Rawalpindi city, police records were more likely to be complete for violence related deaths as compared to injuries due to same mechanism. As compared to ED, police reported DSH related injuries and deaths far less than those due to other types of violence.

Is religiosity a protective factor against attempted suicide: a cross-cultural case-control study

This cross-cultural study investigates whether religiosity assessed in three dimensions has a protective effect against attempted suicide. Community controls (n = 5484) were more likely than suicide attempters (n = 2819) to report religious denomination in Estonia (OR = 0.5) and subjective religiosity in four countries: Brazil (OR = 0.2), Estonia (OR = 0.5), Islamic Republic of Iran (OR = 0.6), and Sri Lanka (OR = 0.4). In South Africa, the effect was exceptional both for religious denomination (OR = 5.9) and subjective religiosity (OR = 2.7). No effects were found in India and Vietnam. Organizational religiosity gave controversial results. In particular, subjective religiosity (considering him/herself as religious person) may serve as a protective factor against non-fatal suicidal behavior in some cultures.

An analysis of WHO data on lethal violence: relevance of the New Western Millennium

INTRODUCTION

Suicide and homicide are considered to be lethal violent acts with a clear difference in their directions, that is, inwardly "killing oneself" or outwardly "killing another," respectively. There are some studies in which these 2 violent acts are considered under the same framework mostly within Western countries. This article for the first time investigates this issue throughout the world. Material and methods. The present study uses data that have been estimated by Global Burden of Disease (GBD) project for 2000 for the 6 different regions of the world proposed by WHO. The suicide/homicide ratio has been calculated by dividing the suicide rate by the sum of the suicide and homicide rates within each age and sex groups. Findings. Three distinct groups have emerged. In the first group, that is, Southeast Asia, Europe, and Western Pacific, lethal violence in both males and females usually directs inward whereas in the second group, that is, Africa, lethal violence in both males and females directs outward. In the third group, that is, America and Eastern Mediterranean, in males lethal violence generally directs outward whereas in females it often directs inward.

CONCLUSION

Under the same framework if a factor causes external blame for the people's failures it will increase the likelihood that the suicide/homicide ratio is expressed as homicide and vice versa. Although this might explain the observed pattern to some extent, more in-depth studies are needed to better understand the causal root of the pattern.

Explaining Suicide in an Urban Slum of Mumbai, India

Background: Health demographic mortality studies use verbal autopsies to identify suicide as a cause of death. Psychological autopsies focus almost exclusively on associated high-risk psychiatric disorders. New approaches considering contextual factors are needed for preventing suicide and promoting mental health. Aims: This study examined explanations of suicide reported by surviving family members or close friends with reference to social, cultural, and environmental conditions as well as the challenges of life in the Malavani slum of Mumbai. Methods: An EMIC (Explanatory Model Interview Catalog) interview based on a cultural epidemiological framework considered underlying problems, perceived causes, and sociocultural contexts. It was administered to survivors of 76 people who had died by suicide (56.6% women). Results: Accounts of underlying problems typically referred to various aspects of tension (73.7%). Perceived causes often identified multiple factors. The sociocultural contexts of suicide included the victimization of women, the personal and social impact of problem drinking, marital problems, physical health problems, mental tension, possession and sorcery. Women were particularly vulnerable to the impact of problem drinking by a spouse or father. Conclusions: This study demonstrates the value of an approach to sociocultural autopsy examining local contexts and explanations of suicide. Findings highlight needs for both mental health services and culturally sensitive social interventions.

Measuring Hopelessness and Life Orientation in Pakistani Adolescents

Background: To gain information on the attitudes and life orientations of Pakistani adolescents, the present study aimed at measuring hopelessness and hopefulness in Pakistani adolescents. Methods: The Beck Hopelessness Scale (BHS; Beck, Weissman, Lester, & Trexler, 1974 ) and the Life Orientation Test (LOT; Scheier & Carver, 1985 ; Scheier, Carver, & Bridges, 1994 ) were translated into Urdu and validated for use in Pakistan. Back translation with a committee approach was used to translate the scales. The translated versions were administered to 723 adolescents and young adults in Pakistan. Results: For the Urdu-BHS, all item-total correlation coefficients were significant and yielded a single component. The principal component analysis on the Urdu-LOT yielded two components representing positively worded Optimism items and negatively worded Pessimism items. The BHS, as well as the two subscales of the LOT, were found to be predictive of suicide ideation. Gender comparisons showed that the two genders differed significantly on Hopelessness and the Optimism component of the Urdu-LOT. Conclusions: The Urdu version of the BHS and the LOT are established for use with young Pakistanis, after translations, and reliability and validity analyses. The need for further empirical research is emphasized for understanding the concepts and antecedents of hopelessness, optimism, and pessimism in adolescents, generally and in Pakistani adolescents, specifically.

Deliberate Self-Harm in the Emergency Department

Background: Suicidal behavior is an understudied subject in Pakistan, a South-Asian developing country with a predominantly Muslim population. Aims: This study examined the characteristics and management of patients presenting with Deliberate Self-Harm (DSH) to the Emergency Department (ED) of a tertiary care teaching hospital in Karachi, Pakistan. Methods: A retrospective chart review of all patients (n = 98), over a period of 12 months was carried out. The demographic details of patients; method of DSH and, if drugs were used, their type, route, and quantity; reason for DSH; past psychiatric history; and outcome were recorded. Results: The mean age of subjects was 23.5 years. The majority of patients were female; most had used drugs for DSH. After initial treatment in the ED, 34 patients were admitted to medical wards for further treatment, 12 were discharged from ED, while 52 patients left against medical advice. The main reasons for leaving against medical advice were financial constraints and fear of legal issues. Seven patients had at least one previous episode of DSH. Conclusions: Patients who left the ED without psychosocial assessment are at increased risk for repetition of DSH as well as suicide.

Suicide among adults aged 30-49: a psychological autopsy study in Hong Kong

Background

A surge in suicide rates in middle age people in Hong Kong and many Asian countries was recently observed. However, there is a paucity of suicide research on this subgroup of people in Asia.

Methods

The next-of-kin of 85 suicide cases and 85 community subjects aged 30–49 years were interviewed by a psychological autopsy approach. Information was triangulated by interview notes, coroner's court files, and police investigation reports.

Results

A multiple logistic regression analysis identified the following risk factors for suicide among the middle age people in Hong Kong: the presence of at least one psychiatric disorder (OR = 37.5, 95% CI 11.5–121.9, p < 0.001), indebtedness (OR = 9.4, 95% CI 2.2–40.8, p < 0.01), unemployment (OR = 4.8, 95% CI 1.3–17.5, p < 0.05), never married (OR = 4.2, 95% CI 1.1–16.3, p < 0.05), and lived alone (OR = 3.9, 95% CI 1.2–13.4, p < 0.05).

Conclusion

The data show that socio-economical factors had a strong impact on suicide in the target group. Further research is needed to explore any positive qualities that protect the middle-aged from suicide. The prevention of suicide in the middle-aged requires multiple strategies.

Validation of the Urdu translation of the Beck Scale for Suicide Ideation

This study aimed at developing an Urdu version of the Beck Scale for Suicide Ideation (BSI) for use with Pakistani adolescents and young adults. For this purpose, the English BSI was translated into Urdu and tested for psychometric properties. The analyses were carried out with data from a sample of 904 adolescents and young adults from eight major cities of Pakistan. The Cronbach's alpha of .75 showed that the Urdu version of the BSI has reasonable internal consistency. Principal Component Analysis gave one meaningful component that indicated Active Suicidal Desire. This preliminary validation study of the Urdu version of the BSI showed that it is an acceptable measure to be used with Pakistani adolescents and young adults. The need for further research on suicide in Pakistan is discussed.

Prevention of Deaths from Intentional Pesticide Poisoning

Abstract. Ingestion of pesticides is the most common suicide method worldwide, accounting for one third of all suicides, predominantly in Asia, Africa, Central and South America. Case fatalities are high, particularly in rural areas. This high case fatality may explain the similar numbers of male and female suicides in Asia, since more women die from their attempts. In Asia, pesticide suicides are mostly impulsive acts with little advance planning and they are less often associated with mental illness than in Western countries. Pesticides are generally chosen for their easy access. Prevention strategies include treating the problems leading to suicidal behaviors involving pesticides; changing attitudes, knowledge, and beliefs about pesticides; controlling access to dangerous pesticides, including developing secure storage practices (which are currently being evaluated); and improving the medical treatment of poisonings. More research is needed to better understand suicides involving pesticides in their cultural contexts and to evaluate the effectiveness of intervention programs, including assessment of possible substitution of methods. Also, more knowledge about protective factors may help suggest innovative prevention strategies.

Suicide in Bahrain in the Last Decade

Abstract. A combination of social, legal, and religious factors make reporting of suicide difficult in Bahrain, an Islamic country. Limited available data indicates a very low incidence rate of 3 per 100,000. The objective of the present study was to describe the pattern of suicide in Bahrain during a 10-year period. The registered suicide cases (N = 304) at the Ministry of Interior for the 10-year period from 1995 to 2004 were reviewed and analyzed. The mean suicide rate was 0.6 per 100,000 for the Bahraini nationals and 12.6 per 100,000 for the non-Bahrainis with and 17.7 per 100,000 for the Indian migrants. Men were six times more likely than women to commit suicide. The majority of the subjects were under 35 years of age with financial domestic problems being the most common reason reported in the record and hanging the mostly commonly used mode of suicide (92.8%). The suicide rate for the Bahraini population remains low compared to other countries. The higher rate of suicide among Indians merits further investigation. Moreover, more research is needed on the epidemiology of suicide risk factors in ethnic groups for further prevention and intervention.

Intimate partner violence and minor psychiatric morbidity of aboriginal Taiwanese women

OBJECTIVES

Experiences of abuse increase the risk of psychiatric morbidity in women. This study assesses the prevalence of intimate partner violence and minor psychiatric morbidity and analyzes their association among aboriginal women in Taiwan.

METHODS

Using system random sampling, 840 aboriginal women between the ages of 18 and 50 years old were recruited from four townships with aboriginal communities in southern Taiwan. Trained primary care nurses interviewed the participants at home by structured questionnaire.

RESULTS

One hundred twenty-six of 840 (15%) of the aboriginal women had experienced physical abuse perpetrated by an intimate partner (her husband or cohabitant) during their lifetime; 10.1% had experienced it during the past 12 months; 4.0% had experienced sexual abuse by the partner; and 6.3% had experienced physical abuse during childhood at the hands of one or both parents. Multiple logistic regression revealed that after adjusting for women's age, alcohol and drug use, religious activity and husband's employment status, the experience of abuse (including partner physical abuse, partner sexual abuse, and childhood physical abuse) was significantly associated with suicidal ideation and depression.

CONCLUSIONS

Health care professionals need to provide adequate support and health education, develop interventions, and use referrals in primary care in the community in order to reduce and prevent domestic violence against aboriginal women in Taiwan.