Suicide and Its Legal Implications in Pakistan: A Literature Review

Situation Analysis of Suicide and Self-Harm in the WHO Eastern Mediterranean Region

OBJECTIVE

An estimated 41,000 lives are lost to suicide each year in World Health Organization Eastern Mediterranean Region Office (WHO EMRO) countries. The objective of this study was to conduct a situation analysis for suicide and self-harm in the WHO EMRO region.

METHODS

Data on suicide were obtained from the WHO Global Health Estimates for the years 2000-2019. Information on risk groups efforts to prevent self-harm and suicide in the EMRO region were retrieved through scientific studies, grey literature, and public websites.

RESULTS

During 2000-2019, the age-standardized suicide rate was 6.7 per 100,000 inhabitants, albeit there are concerns regarding data quality. Self-harm and suicide remain criminal acts in more than half of the countries. Few countries have a national plan for prevention of suicide. Toxic agents, such as pesticides and black henna, are easily available and frequently used for suicide in some areas, as are firearms and self-immolation. Successful prevention measures include means restriction and psychosocial interventions after self-harm.

CONCLUSION

Many WHO EMRO countries remain underserved in terms of mental health care. Decriminalization of suicide and means restriction might be further promoted. Online-based tools for mental health literacy and psychosocial therapy are other options to explore.

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.

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.

Suicides in Turkey: 25-year trend (1995-2019)

The assessment of national suicide risks is considered critical in many countries for the establishment of suicide prevention initiatives aimed at considerably lowering suicide rates. The aim of this study is to identify at-risk suicide populations by reviewing the suicides in Turkey over a 25-year period. The Turkish Statistical Institute's suicide statistics for 1995-2019 in Turkey was retrospectively reviewed in current article. The data collected in the study was statistically analyzed using the MINITAB vn 14 software. Between 1995 and 2019, the total number of suicides in Turkey was 66,819, and suicide rates, especially in males, showed an increasing trend in this period. Males comprised 68.3% of the total cases, and most (27.2%) were aged 15-24 years. Suicides mostly occurred between May and July (27.7%), of individuals with a primary school level of education (51.7%) and who were married (6.0 per 100,000). Illness was most important risk factor for suicide (36.8%) and hanging (47.5%) was the leading suicide method in all age groups and in both genders. Despite the fact that Turkey's suicide rate is lower than many other countries, the growth in male suicide rates is concerning. Suicides are likely to become a severe problem in Turkey in the near future unless measures like education, psychiatric evaluations, the reactivation of psychological counseling service phone lines, and the establishment of youth counseling centers, as described in this paper, are taken.

An analysis of age-standardized suicide rates in Muslim-majority countries in 2000-2019

BACKGROUND

This study examines the 20-year trend of suicide in 46 Muslim-majority countries throughout the world and compares their suicide rates and trends with the global average. Ecological-level associations between the proportion of the Muslim population, the age-standardized suicide rates, male-to-female suicide rate ratio, and the Human Development Index (HDI) in 2019 were examined.

METHODS

Age-standardized suicide rates were extracted from the WHO Global Health Estimates database for the period between 2000 and 2019. The rates in each country were compared with the age-standardized global average during the past 20 years. The countries were further grouped according to their regions/sub-regions to calculate the regional and sub-regional weighted age-standardized suicide rates involving Muslim-majority countries. Correlation analyses were conducted between the proportion of Muslims, age-standardized suicide rate, male: female suicide rate ratio, and the HDI in all countries. Joinpoint regression was used to analyze the age-standardized suicide rates in 2000-2019.

RESULTS

The 46 countries retained for analysis included an estimated 1.39 billion Muslims from a total worldwide Muslim population of 1.57 billion. Of these countries, eleven (23.9%) had an age-standardized suicide rate above the global average in 2019. In terms of regional/sub-regional suicide rates, Muslim-majority countries in the Sub-Saharan region recorded the highest weighted average age-standardized suicide rate of 10.02/100,000 population, and Southeastern Asia recorded the lowest rate (2.58/100,000 population). There were significant correlations between the Muslim population proportion and male-to-female rate ratios (r=-0.324, p=0.028), HDI index and age-standardized suicide rates (r=-0.506, p<0.001), and HDI index and male-to-female rate ratios (r=0.503, p<0.001) in 2019. Joinpoint analysis revealed that seven Muslim-majority countries (15.2%) recorded an increase in the average annual percentage change regarding age-standardized suicide rates during 2000-2019.

CONCLUSIONS

Most Muslim-majority countries had lower age-standardized suicide rates than the global average, which might reflect religious belief and practice or due to Muslim laws in their judicial and social structure which may lead to underreporting. This finding needs further in-depth country and region-specific study with regard to its implication for public policy.

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.

Crime and punishment: Pakistan's legal failure to account for mental illness

The Mental Health Ordinance 2001 was the last comprehensive legislation on mental health policy in Pakistan, replacing the Lunacy Act 1912. Since then, most of the amendments to the act have only delineated the jurisdiction of the provincial governments. Failure to account for mental illness in Pakistan brings with it unique challenges, such as the criminalisation of suicide and exploitation of blasphemy laws. There is a need for organised efforts to promote awareness of mental illness, amend the obsolete legislation in conformity with the scientific evidence, implement mental health policy effectively and deal with sensitive issues that have a strong sociocultural or religious background.

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.

Suicide by poisoning in Pakistan: review of regional trends, toxicity and management of commonly used agents in the past three decades

BACKGROUND

Suicide is one of the leading mental health crises and takes one life every 40 seconds. Four out of every five suicides occur in low- and middle-income countries. Despite religion being a protective factor against suicide, the estimated number of suicides is rapidly increasing in Pakistan.

AIMS

Our review focuses on the trends of suicide and means of self-poisoning in the past three decades, and the management of commonly used poisons.

METHOD

We searched two electronic databases (PubMed and PakMediNet) for published English-language studies describing agents used for suicide in different regions of Pakistan. A total of 46 out of 85 papers (N = 54 747 cases) met our inclusion criteria.

RESULTS

Suicidal behaviour was more common among individuals younger than 30 years. Females comprised 60% of those who attempted suicide in our study sample, although the ratio of completed suicides favoured males. There were regional trends in the choice of agent for overdose. Organophosphate poisoning was reported across the nation, with a predominance of cases from the agricultural belt of South Punjab and interior Sindh. Aluminium phosphide ('wheat pills') was a preferred agent in North Punjab, whereas paraphenylenediamine ('kala pathar') was implicated in deaths by suicide from South Punjab. Urban areas had other means for suicide, including household chemicals, benzodiazepines, kerosene oil and rat poison.

CONCLUSIONS

Urgent steps are needed, including psychoeducational campaigns on mental health and suicide, staff training, medical resources for prompt treatment of self-poisoning and updated governmental policy to regulate pesticide sales.

Wellness Services: A Need Assessment Survey for Post Graduate Medical Education Trainees at Aga Khan University Hospital, Pakistan

OBJECTIVE

The study aimed to assess the need of mental wellbeing services for post graduate medical (PGME) trainees working at the Aga Khan University Hospital in Karachi, Pakistan.

METHODS

A cross-sectional study was conducted among all PGME trainees working at Aga Khan University Hospital in Karachi, Pakistan. The study questionnaire was developed by the team of investigators. The data collection was done through online survey from April 2019 to May 2019 and it was analyzed using descriptive and inferential analyses.

RESULTS

Out of total 623 PGME trainees, 334 trainees completed the online survey (response rate of 53.61%). A total of 292 participants (87.4%) perceived a need for mental health services. The major stressors identified were increase work hours (77.8%), excessive workload (75.1%), and difficulty balancing between work and personal life (72.8%). The perceived obstacles of utilizing mental services included lack of protected time (69.8%), fear of consequences (36.8%), lack of confidentiality (36.5%), and stigma (32.9%). The study participants indicated various suggestions to reduce their stressors such as separate relaxation space in hospital (91.3%), appreciation gestures like encouraging emails (65%), mentoring programs (43.4%), and regular surveys about resident needs (39.8%).

CONCLUSION

It is evident that innovative strategies to address trainees' mental health needs, looking at limitations of developing countries like Pakistan with large population and limited resources, need to be explored.

Depression in Chronically ill Patients of Railway General Hospital, Pakistan

According to the World Health Organization (WHO), chronic diseases are the leading cause of death and disability worldwide and estimated to contribute to 73% of all deaths by 2020. In addition to the difficulty in effectively managing chronic diseases, they are often complicated further by the co-morbid depression stemming from the original disease. Depression has the highest burden of disease affecting more than 264 million people worldwide and worsens the burden of co-existing chronic medical diseases as well. A bidirectional relation exists between depression and chronic medical diseases. Statistical mapping of chronically ill patients of Pakistan suggests that 50% of its population suffers from some form of chronic disease. Little data exists for the prevalence of depression in chronically ill patients from most of Pakistan. Our objectives were to observe the patterns of depression in chronically ill patients and outline the need for intervention (if any) on a population of Railway General Hospital (RGH - a tertiary healthcare hospital in Rawalpindi, Pakistan). We also aimed at finding out the relation (if any) of age, gender, number of hospital admissions, education and effectiveness of medical disease management with depression. A cross sectional study was conducted on patients admitted due to their chronic medical diseases out of a population of 11,000 presenting at the medical OPD of RGH over a period of three months using Patient Health Questionnaire-9 (PHQ -9) Urdu version. About 50% of the patients suffered from moderate to severe forms of depression. A significant positive correlation was found between age and past psychiatric history of illnesses other than depression with depression while no significance was found with number of hospital admissions, gender or education level; 35% had suicidal ideation. Depression is quite often dismissed, underdiagnosed and leads to a poor quality of life and decrease in cost effectiveness in our population. Pakistan needs to use more resources on managing depression and medical professionals need to change their attitudes in holistically managing the patients. Treating depression is just as important as managing other symptoms of chronic medical diseases.