Suicide Prevention: Beyond Mental Disorder

Suicide Ideation within and outside the Perinatal Period: An Exploration of Interpersonal Factors from a Maternal Cohort in Rural Pakistan to Improve Intervention Targeting

OBJECTIVE

Suicide accounts for substantial mortality in low-resourced settings and contributes to nearly 20% of maternal deaths. In Asia, interpersonal conflict is a salient factor that contributes to suicidal thoughts and actions, yet limited research has been done to explore the type and timing of such conflicts and a woman's accompanying social support. Identifying such risk factors can inform improved efforts to identify who to target for psychosocial interventions.

METHODS

Using the Bachpan Cohort study of mothers in Pakistan (n = 1154), we examined the prevalence and interpersonal influences on SI within the past two weeks of pregnancy and then at 3, 6, and 24 months after birth. Using hierarchical mixed effects models, we explored the separate and combined associations of interpersonal factors [e.g., social support, interpersonal conflict, isolation, and past year intimate partner violence (IPV)] on SI at each timepoint.

RESULTS

SI prevalence was highest in pregnancy (12.2%) and dropped to 5% throughout two years postpartum. The interpersonal conflict was independently associated with increased odds of SI in pregnancy and 24 months postpartum. IPV was associated with increased SI in pregnancy and 24 months postpartum. Isolation was not associated with SI at any timepoint. Perceived social support remained a robust independent factor associated with reduced SI at all timepoints.

CONCLUSION

In addition to screening and deploying interventions for perinatal women with depression, targeting interventions for those who also experience interpersonal conflict, including intimate partner violence, may significantly reduce suicidal thoughts and related sequelae. Social support is a viable and potentially powerful target to reduce the burden of suicide among women.HIGHLIGHTSSuicidal ideation prevalence was higher in pregnancy compared to postpartum.Perceived social support was independently associated with reduced suicidal ideation.Interventions addressing suicide must attend to women's family and social context.

Study of suicide burden of mortality in México 1990-2017

OBJECTIVE

The primary goal was to analyze the level and trend of the burden of suicide mortality in Mexico between 1990 and 2017 at a national and state scale.

METHODS

A secondary analysis based on the 2017 global burden of disease study. Mortality rates and years of life lost due to premature death (YLL) were reported here. A joinpoint regression analysis based on a log-linear model was used to analyze the trend of YLL.

RESULTS

The burden of disease due to suicides increased in Mexico, mainly in young males and females; though the raise that happened in the elderly is an additional challenge for the health system. The burden of disease varied substantially between states. The male mortality rates were higher than those of females during the whole period under study, nonetheless with a trend to reduce the difference between the sexes. A bimodal pattern of the burden of disease due to suicide in Mexico was also observed, with the higher rates located in those aged between 15 and 19 years, and an important increase in people older than 85 years of age.

CONCLUSION

These results show a worrisome picture, not only from a social, economic and health point of view but also from the needs of public policies. This situation represents a wake-up call about the need to implement timely identification actions, a comprehensive multisectoral prevention strategy and the detailed study of suicide associated risk factors.

Gender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990-2016

Background

A systematic understanding of suicide mortality trends over time at the subnational level for India's 1·3 billion people, 18% of the global population, is not readily available. Thus, we aimed to report time trends of suicide deaths, and the heterogeneity in its distribution between the states of India from 1990 to 2016.

Methods

As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016, we estimated suicide death rates (SDRs) for both sexes in each state of India from 1990 to 2016. We used various data sources for estimating cause-specific mortality in India. For suicide mortality in India before 2000, estimates were based largely on GBD covariates. For each state, we calculated the ratio of the observed SDR to the rate expected in geographies globally with similar GBD Socio-demographic Index in 2016 (ie, the observed-to-expected ratio); and assessed the age distribution of suicide deaths, and the men-to-women ratio of SDR over time. Finally, we assessed the probability for India and the states of reaching the Sustainable Development Goal (SDG) target of a one-third reduction in SDR from 2015 to 2030, using location-wise trends of the age-standardised SDR from 1990 to 2016. We calculated 95% uncertainty intervals (UIs) for the point estimates.

Findings

There were 230 314 (95% UI 194 058–250 260) suicide deaths in India in 2016. India's contribution to global suicide deaths increased from 25·3% in 1990 to 36·6% in 2016 among women, and from 18·7% to 24·3% among men. Age-standardised SDR among women in India reduced by 26·7% from 20·0 (95% UI 16·5–23·5) in 1990 to 14·7 (13·1–16·2) per 100 000 in 2016, but the age-standardised SDR among men was the same in 1990 (22·3 [95% UI 14·4–27·4] per 100 000) and 2016 (21·2 [14·6–23·6] per 100 000). SDR in women was 2·1 times higher in India than the global average in 2016, and the observed-to-expected ratio was 2·74, ranging from 0·45 to 4·54 between the states. SDR in men was 1·4 times higher in India than the global average in 2016, with an observed-to-expected ratio of 1·31, ranging from 0·40 to 2·42 between the states. There was a ten-fold variation between the states in the SDR for women and six-fold variation for men in 2016. The men-to-women ratio of SDR for India was 1·34 in 2016, ranging from 0·97 to 4·11 between the states. The highest age-specific SDRs among women in 2016 were for ages 15–29 years and 75 years or older, and among men for ages 75 years or older. Suicide was the leading cause of death in India in 2016 for those aged 15–39 years; 71·2% of the suicide deaths among women and 57·7% among men were in this age group. If the trends observed up to 2016 continue, the probability of India achieving the SDG SDR reduction target in 2030 is zero, and the majority of the states with 81·3% of India's population have less than 10% probability, three states have a probability of 10·3–15·0%, and six have a probability of 25·1–36·7%.

Interpretation

India's proportional contribution to global suicide deaths is high and increasing. SDR in India is higher than expected for its Socio-Demographic Index level, especially for women, with substantial variations in the magnitude and men-to-women ratio between the states. India must develop a suicide prevention strategy that takes into account these variations in order to address this major public health problem.

Funding

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Suicide in Nepal: Qualitative Findings from a Modified Case-Series Psychological Autopsy Investigation of Suicide Deaths

South Asia accounts for the majority of the world's suicide deaths, but typical psychiatric or surveillance-based research approaches are limited due to incomplete vital surveillance. Despite rich anthropological scholarship in the region, such work has not been used to address public health gaps in surveillance and nor inform prevention programs designed based on surveillance data. Our goal was to leverage useful strategies from both public health and anthropological approaches to provide rich narrative reconstructions of suicide events, told by family members or loved ones of the deceased, to further contextualize the circumstances of suicide. Specifically, we sought to untangle socio-cultural and structural patterns in suicide cases to better inform systems-level surveillance strategies and salient community-level suicide prevention opportunities. Using a mixed-methods psychological autopsy approach for cross-cultural research (MPAC) in both urban and rural Nepal, 39 suicide deaths were examined. MPAC was used to document antecedent events, characteristics of persons completing suicide, and perceived drivers of each suicide. Patterns across suicide cases include (1) lack of education (72% of cases); (2) life stressors such as poverty (54%), violence (61.1%), migrant labor (33% of men), and family disputes often resulting in isolation or shame (56.4%); (3) family histories of suicidal behavior (62%), with the majority involving an immediate family member; (4) gender differences: female suicides were attributed to hopeless situations, such as spousal abuse, with high degrees of social stigma. In contrast, male suicides were most commonly associated with drinking and resulted from internalized stigma, such as financial failure or an inability to provide for their family; (5) justifications for suicide were attributions to 'fate' and personality characteristics such as 'stubbornness' and 'egoism'; (5) power dynamics and available agency precluded some families from disputing the death as a suicide and also had implications for the condemnation or justification of particular suicides. Importantly, only 1 out of 3 men and 1 out of 6 women had any communication to family members about suicidal ideation prior to completion. Findings illustrate the importance of MPAC methods for capturing cultural narratives evoked after completed suicides, recognizing culturally salient warning signs, and identifying potential barriers to disclosure and justice seeking by families. These findings elucidate how suicide narratives are structured by family members and reveal public health opportunities for creating or supplementing mortality surveillance, intervening in higher risk populations such as survivors of suicide, and encouraging disclosure.

Suicide in Nepal: a modified psychological autopsy investigation from randomly selected police cases between 2013 and 2015

PURPOSE

Yearly, 600,000 people complete suicide in low- and middle-income countries, accounting for 75% of the world's burden of suicide mortality. The highest regional rates are in South and East Asia. Nepal has one of the highest suicide rates in the world; however, few investigations exploring patterns surrounding both male and female suicides exist. This study used psychological autopsies to identify common factors, precipitating events, and warning signs in a diverse sample.

METHODS

Randomly sampled from 302 police case reports over 24 months, psychological autopsies were conducted for 39 completed suicide cases in one urban and one rural region of Nepal.

RESULTS

In the total police sample (n = 302), 57.0% of deaths were male. Over 40% of deaths were 25 years or younger, including 65% of rural and 50.8% of female suicide deaths. We estimate the crude urban and rural suicide rates to be 16.1 and 22.8 per 100,000, respectively. Within our psychological autopsy sample, 38.5% met criteria for depression and only 23.1% informants believed that the deceased had thoughts of self-harm or suicide before death. Important warning signs include recent geographic migration, alcohol abuse, and family history of suicide.

CONCLUSIONS

Suicide prevention strategies in Nepal should account for the lack of awareness about suicide risk among family members and early age of suicide completion, especially in rural and female populations. Given the low rates of ideation disclosure to friends and family, educating the general public about other signs of suicide may help prevention efforts in Nepal.