Perceptions of Suicide among Pakistanis: Results of an Online Survey.

OBJECTIVE: In Pakistan, a predominantly Muslim country, information on the patterning of suicidal thoughts and behaviors, as well as associated public perceptions and opinions, is limited. We sought to advance knowledge on suicide and self-harm in Pakistan with a large, online survey. METHOD: Leveraging results from a twelve-item online survey (N = 5,157) circulated by the largest English language newspaper in Pakistan, we assessed personal experiences, opinions, and attitudes toward help-seeking in the context of suicide. We calculated proportions with 95% confidence intervals for endorsed responses and implemented binomial generalized linear models with odds ratios to assess differing response tendencies by age, gender, and urban/rural residence. RESULTS: Personal experiences related to suicide and self-harm as well as encounters in social circles were common. Mental illness tended to be recognized as a high likelihood contributor to suicide death over and above nonviolent interpersonal problems. Most considered suicide a way to escape pain, and few considered suicide to be immoral. Barriers to help-seeking included social deterrents, inaccessibility, and unaffordability. Women and youth emerged as higher risk groups, though the status of rural Pakistanis remained unclear. CONCLUSION: The survey provides a preliminary basis for considering the unique experiences and perspectives of the public in shaping suicide prevention and intervention efforts in Pakistan.

A voluntary online survey about suicide with over 5,000 responses from a cross-section of Pakistani populationResults illuminate popular opinions on suicide risk and mental health treatmentWomen and youth appear to be especially vulnerable warranting targeted intervention.

Assessing knowledge, attitudes, and practices of emergency department staff towards patients with suicidal behaviors in Pakistan.

The study aimed to assess knowledge, attitudes and practices of Emergency Department staff towards patients with suicidal behaviors at a tertiary care hospital in Karachi Pakistan. An online survey found that majority of respondents were unaware of the law regarding suicide and self-harm (SH) in Pakistan. Majority had not received any specific training in management of suicidal patients. About 50 % of doctors and 16 % of nurses felt that SH patients are treated 'less seriously than patients with medical problems.' Institutional policy on management and pathway to care for suicidal patients should be disseminated and monitored for its implications in clinical practice.

Patterns of suicide and self-harm in Pakistan: a retrospective descriptive study protocol.

INTRODUCTION: Suicide is a major global public health problem. Low-income and middle-income countries contribute 78% of all suicidal deaths. Pakistan, a South Asian country, lacks official statistics on suicides at national level. Statistics on suicide are neither collected nationally nor published in the annual national morbidity and mortality surveys. Medicolegal reports on suicides and self-harm are extremely rich and important source of information but greatly underused in Pakistan. We aim to examine the patterns of suicides and self-harm retrospectively in patients who were registered with medicolegal centres (MLCs) in Karachi, during the period January 2017 to December 2021. METHODS AND ANALYSIS: Using retrospective descriptive design, the data will be collected from the medical records maintained at the main office of the Karachi police surgeon. Data from all nine MLCs of Karachi are collated and stored at the main office of Police surgeon. Information on suicide and self-harm cases will be extracted from records of all MLCs. The data will be collected using structured proforma and it will be analysed using descriptive and inferential analysis. ETHICS AND DISSEMINATION: The study was approved for exemption from Aga Khan University, Ethical Review Committee. The findings of the study will be disseminated by conducting seminars for healthcare professionals and stakeholders including psychiatrists, psychologists, counsellors, medicolegal officers, police surgeons, mental health nurses, general and public health physicians and policy makers. Findings will be published in local and international peer-reviewed scientific journals.

Association between Suicide Rate and Human Development Index, Income, and the Political System in 46 Muslim-Majority Countries: An Ecological Study.

Very little has been researched assessing the relationship between the suicide rate and the ecological perspectives of the country, especially in the Muslim majority countries. We aimed to determine the association between suicide rate and the ecological parameters of 46 Muslim majority countries. We extracted the Muslim majority countries and their suicide rate, income distribution, distribution of the WHO region and continents, and Human Development Index (HDI). We assessed the correlation of the proportion of Muslim populations, the total population of the countries, number of suicides, continent, income group, political system, and HDI score with the suicide rate. The median suicide rate was 5.45 (IQR = 4.8); 2.9 (IQR = 4) in females and 7.45 (IQR = 8.2) in males per 100,000 population. The males had a significantly higher rate and the highest suicide rate was found in Africa. There are inverse associations between the total suicide rate, the rate in males, and females with HDI, and the income of the country. Furthermore, the suicide rate was significantly higher in countries with democratic systems compared to non-democratic countries. The findings suggest that ecological parameters may have an etiological role on suicides in Muslim countries where HDI and income are inversely associated with suicide rates.

Suicide prevention in Bangladesh: The role of family.

BACKGROUND: Suicide is a public health problem that gets little attention in Bangladesh especially in prevention aspects. Recent studies revealed that a significant portion of risk factors is closely related to family events. However, potential prevention strategies considering the family structure and involving family dynamics of Bangladesh have not been discussed. OBJECTIVES: We aim to highlight areas of family vulnerability and resilience when the threat of suicide is present, as well as the potential roles of family in suicide prevention in Bangladesh. METHODS: We conducted a thorough narrative and focused literature search and synthesized evidence based on available articles discussing suicidality and family dynamics in Bangladesh. RESULTS: Risk factors for suicide prevailing in the family have been organized, and several strategies for coping with family risk factors, including marital discord and family conflict have been proposed for testing empirically. CONCLUSIONS: The family has an important role to play in suicide prevention in Bangladesh. However, potential prevention strategies and their effectiveness have been untapped in the country. Studies are warranted to test the effectiveness of the proposed strategies.

Population attributable fractions of clinical and social risk factors for suicide in Bangladesh: Finding from a case-control psychological autopsy study.

BACKGROUND: Our knowledge of suicide in low-income countries is limited. Understanding the importance of factors that contribute to suicide risk will allow for the appropriate allocation of limited resources. In order to prioritize suicide prevention activities in Bangladesh, we estimate the fractions of suicides attributable to key risk factors. METHODS: Using data from matched cases (100) and controls (100) as part of a psychological autopsy study in Dhaka, we estimate the population attributable fraction for key clinical (psychiatric disorders and physical disability), and social (life events, psychical and/or sexual abuse, unemployment, and social isolation) risk factors for suicide in Bangladesh. RESULTS: Assuming a causal relationship, life events were responsible for the largest proportion of suicide deaths (85.9%; confidence interval [CI], 79.6-90.2), followed by mental disorder (49.5%; CI, 45.3-53.4). The population attributable fraction for the risk factors was 42.9% (CI, 40.6-45) for depression, 11% (CI, 8.9-13) for sexual abuse, and 34.9% (CI, 10.1-52.9) for social isolation. CONCLUSIONS: The study determined the population attributable fraction of risk factors for suicide in Bangladesh. Prevention strategies should be prioritized on the management of the aftermaths of adverse life events, treatment of psychiatric disorders, sexual abuse, and social isolation in the country.

Psychological autopsy study and risk factors for suicide in Muslim countries.

BACKGROUND: Suicide and risk factors have been poorly studied in the Muslim-majority countries that hinder the formulation of prevention strategies and affect suicide prevention eventually. OBJECTIVES: We aimed at identifying and analyzing the psychological autopsy studies assessing the risk factors for suicide conducted in Muslim-majority countries. METHODS: We did a search to trace all the available psychological autopsy studies in the Muslim countries with the search term "psychological autopsy study in Muslim countries." We also checked the available bibliographies to identify the psychological autopsy studies in the Muslim countries so that all the possible studies could be included. RESULTS: Out of the Muslim countries, only eight psychological autopsy studies were identified in five countries (Bangladesh [1], Indonesia [1], Iran [1], Pakistan [2], and Turkey [3]). Six studies adopted a case-control study design, and all were carried out in urban settings. The prevalence of psychiatric disorders among case-control studies varied from 52.8% in Turkey to 96% in Pakistan. Psychiatric illness, self-harm, and stressful life events were the commonly replicated risk factors for suicide across studies. CONCLUSIONS: Psychological autopsy studies have been conducted only in five Muslim countries revealing that the risk factor for suicide is certainly under-researched in the incumbent countries. This review identified a similar list of risk factors for suicide, namely, psychiatric disorder, past non-fatal attempts, and adverse life events compared to the Western countries even though the rate varies.

Suicide methods in South Asia over two decades (2001-2020).

BACKGROUND: Suicide is a global preventable public health problem. About a quarter of all suicides in the world occur in South Asia. As means restriction is an important suicide prevention strategy, gaining knowledge of the common suicide methods and their changing trends in each country and region is crucial. AIMS: We aimed to assess the suicide methods in South Asian countries over the last two decades. METHODS: A search was performed in PubMed, PubMed Central, Scopus, and Google Scholar with the search terms. Original articles of quantitative studies, published in the English language, from 2001 to 2020, with full-accessible text, that rank different methods of suicide in eight South Asian countries, were included. RESULTS: A total of 68 studies were found eligible for review. The Maximum number of studies were found from India (n = 38), followed by Bangladesh (n = 12), Pakistan (n = 9), Sri Lanka (n = 6), and Nepal (n = 3). Hanging (n = 40, 55.8%) and poisoning (n = 24, 35.3%) were the two most common suicide methods reported, in that order. Hanging followed by poisoning were the commonest suicide methods in Bangladesh, India, and Pakistan while in Sri Lanka, poisoning was the preferred method to hanging. There is a decline in suicide by poisoning and an increase in suicide by hanging in Sri Lanka, Bangladesh, and India. Although hanging is still the commonest method in Pakistan, the use of firearms is growing in recent years (2011-2020). CONCLUSIONS: There is a steady decline in the incidence of suicides by poisoning following pesticide regulations in South Asian countries. However, there is heterogeneity of study methods, probable under-reporting of suicide, and lack of robust suicide data.

Risk factors for suicide in Bangladesh: case-control psychological autopsy study.

BACKGROUND: Suicide is an important, understudied public health problem in Bangladesh, where risk factors for suicide have not been investigated by case-control psychological autopsy study. AIMS: To identify the major risk factors for suicide in Dhaka, Bangladesh. METHODS: We designed a matched case-control psychological autopsy study. We conducted a semi-structured interview with the next-of-kin of 100 individuals who died by suicide and 100 living controls, matched for age, gender and area of residence. The study was conducted from July 2019 to July 2020. RESULTS: The odds ratios for the risk factors were 15.33 (95% CI, 4.76-49.30) for the presence of a psychiatric disorder, 17.75 (95% CI, 6.48-48.59) for life events, 65.28 (95% CI, 0.75-5644.48) for previous attempts and 12 (95% CI, 1.56-92.29) for sexual abuse. CONCLUSIONS: The presence of a psychiatric disorder, immediate life events, previous suicidal attempts and sexual abuse were found as significant risk factors for suicide in Dhaka, Bangladesh.

Assessing the Quality of Media Reporting of Suicide Deaths in Bangladesh Against World Health Organization Guidelines.

Background: Media reporting of suicide events has thus far gone without sufficient scrutiny in Bangladesh. Aim: The purpose of this study was to assess the quality of newspaper reporting of suicides in Bangladesh against international guidelines. Methods: We used content analysis to assess the quality of suicide reporting in six daily newspapers in Bangladesh. The newspapers were hand-searched between November 2016 and April 2017 and 327 articles reporting on suicide deaths were retrieved. Results: The mean number of suicide articles per day per newspaper was 0.3 (range across newspapers 0.11-0.70) and the mean length was 11.3 sentences. Harmful reporting practices were very common (for example, a detailed suicide method was reported in 75.5% of articles) while almost no potentially helpful reporting practices were observed (for example, no articles gave contact details for a suicide support service). Limitations: The findings are limited to print mass media. Conclusions: We observed that explicit and simplistic reports of suicide deaths were frequently observed in newspapers in Bangladesh. Attempts should be made to understand the perspectives of media professionals in relation to suicide reporting, and to devise strategies to boost the positive contribution that media can make to suicide prevention in this context.

Suicide and deliberate self-harm in Pakistan: a scoping review.

BACKGROUND: Suicide is a major global public health problem with more than 800,000 incidents worldwide annually. Seventy-five percent of the global suicides occur in low and middle-income countries (LMICs). Pakistan is a LMIC where information on suicidal behavior is limited. The aim of the review is to map available literature on determinants, risk factors and other variables of suicidal behavior in Pakistan. METHOD: This study was based on Arksey and O'Malley's methodological framework of scoping review, combining peer reviewed publications with grey literature. Ten databases including Applied Social Sciences Index and Abstracts (ASSIA), Cochrane Trials Register (CRG), Cumulative Index to Nursing and Allied Health (CINAHL), National Library of Medicine Gateway (NLMG), ExcerptaMedica (EMBASE), National Library of Medicine's MEDLINE (PUBMED), PSYCHINFO, Social Science Citation Index and Science Citation Index (SCI) and Pakmedinet.com were searched from the beginning of their time frames until December 2016 using a combination of key terms. The inclusion criteria included studies of various study designs covering different aspects of suicidal behavior in English language. RESULTS: Six hundred and twenty three articles were initially retrieved from all ten databases. Two independent reviewers screened the titles and abstracts for relevance. One hundred and eighteen articles were read in full, out of which 11 were excluded because they did not fit the eligibility criteria. One hundred and ten articles, including two student theses and one report, were included in the final review. Most studies were descriptive in nature, with only three that used a case-control design. Majority of the studies were from urban areas, and addressed determinants rather than risk factors. Gender differences and age were predominantly reported, with more males committing suicide. Suicidal behavior was more common among individuals younger than 30 years of age. The three most common methods for suicides were hanging, poisoning and use of firearms. Mental illness as a risk factor for suicides was mentioned in only three studies. CONCLUSIONS: This review is the first attempt to synthesize available literature on suicidal behavior in Pakistan. The evidence is limited, and calls for more robust analytical research designs, along with a focus on risk factors.

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.

Male gender preference, female gender disadvantage as risk factors for psychological morbidity in Pakistani women of childbearing age - a life course perspective.

BACKGROUND: In Pakistan, preference for boys over girls is deeply culturally embedded. From birth, many women experience gendered disadvantages; less access to scarce resources, poorer health care, higher child mortality, limited education, less employment outside of the home and circumscribed autonomy. The prevalence of psychological morbidity is exceptionally high among women. We hypothesise that, among women of childbearing age, gender disadvantage is an independent risk factor for psychological morbidity METHODS: A cross-sectional catchment area survey of 525 women aged 18 to 35 years living in Islamabad and Rawalpindi. The effect of gender disadvantage was assessed as a latent variable using structural equation modelling. Indicators were parental gender preference, low parental care, parental overprotection, limited education, early age at marriage, marital dissatisfaction and low autonomy. Psychological morbidity was assessed using the 20 item Self Reporting Questionnaire (SRQ). RESULTS: Gender disadvantage was independently predictive of psychological morbidity. Among married women, socio-economic status did not predict psychological morbidity, and the effect of education was mediated through gender disadvantage rather than socioeconomic status (SES). The women's own preference for a male child was strongly predicted by their perceptions of having been disadvantaged by their gender in their families of origin. CONCLUSIONS: The high prevalence of psychological morbidity among women in Pakistan is concerning given recently reported strong associations with low birth weight and infant stunting. Social action, public policies and legislation are indicated to reduce culturally embedded preferences. Neglect of these fundamentals will entrench consequent inequities including gender bias in access to education, a key millennium development goal.

How we developed a bioethics theme in an undergraduate medical curriculum.

The 5-year undergraduate medical curriculum at Aga Khan University integrates basic sciences with clinical and community health sciences. Multimodal strategies of teaching and learning, with an emphasis on problem-based learning, are utilized to equip students with knowledge, skills, behaviours, attitudes and values necessary for a high-calibre medical graduate. Bioethics teaching was introduced in the medical curriculum in 1988 and has since undergone several changes. In 2009, a multidisciplinary voluntary group began review of undergraduate bioethics teaching and invested over 350 man-hours in curricular revision. This involved formulating terminal objectives, delineating specific objectives and identifying instructional methodologies and assessment strategies appropriate for the contents of each objective. Innovative strategies were specially devised to work within the time constraints of the existing medical curriculum and importantly, to increase student interest and engagement. The new bioethics curriculum is designed to be comprehensive and robust, and strives to develop graduates who, in addition to being technically skilled and competent, are well-versed in the history and philosophy of ethics and bioethics and are ethical in their thinking and practice, especially in the context of a developing country like Pakistan where health indicators are among the worst in the region, and clinical practices are not effectively regulated to ensure quality of care.

'The one truly serious philosophical problem': Ethical aspects of suicide.

Suicide is a major global public health problem with an estimated one million deaths every year. It is one of the most personal yet one of the most complex acts anyone can perform, as it goes to the very core of the concept of human existence and the meaning of life. The philosophical debate on suicide has spanned centuries with no clear answers. Juxtaposed within the various perspectives that suicide can be studied from is the ethical perspective that brings into sharp focus the conflict between personal autonomy and societal responsibility towards suicidal individuals. Mental health professionals find themselves in the midst of this conflict as they are assumed to have the responsibility to prevent suicide in their patients, while patients' responsibility towards themselves is frequently overlooked. Mental health professionals need to be aware of the ethical concerns that arise in the care of suicidal patients.

The effect of clinical clerkship on students' attitudes toward psychiatry in Karachi, Pakistan.

OBJECTIVE: Attitudes of medical students toward a specialty is strongly related to their future choice of specialty. In developing countries like Pakistan, where there is a shortage of psychiatrists, there is a need to assess the effect of exposure to psychiatry on medical students. METHODS: The authors conducted a survey of fourth-year medical students at Aga Khan University in Karachi, Pakistan. RESULTS: Psychiatry clerkship had an overall positive attitude toward psychiatric illness, patients, and psychiatrists, but no effect on students' choice of psychiatry as a career. CONCLUSION: Psychiatry teaching needs to be made more relevant to the rest of the medical curricula. This may improve students' interest and their future choice of psychiatry as an area of specialization.

Deliberate self-harm in the emergency department: experience from Karachi, Pakistan.

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.