Dinkum Journal of Medical Innovations (DSMI)

Publication History

Submitted: December 02, 2022
Accepted: December 20, 2022
Published: January 01, 2023

Identification

D-0095

Citation

Tahira Amanat, Umm-e-Aiman, Tayyaba Firdus & Zahida Bukhari (2023). A Systematic Literature Review on Suicidal Cases in Pakistan. Dinkum Journal of Medical Innovations, 2(01):12-17.

Copyright

© 2023 DJMI. All rights reserved

A Systematic Literature Review on Suicidal Cases in PakistanReview Article

Tahira Amanat 1, Ume-e-Aiman 2*, Tayyaba Firdus 3, Zahida Bukhari 4           

  1. Fatima Jinnah Medical University, Lahore, Pakistan; amanattahira@gmail.com
  2. Kinnaird College for Women University, Lahore, Pakistan; aimen17032019@gmail.com
  3. School of Allied Health Sciences, Children Hospital Lahore, Pakistan; ahmadtayyaba2@gmail.com
  4. Fatima Jinnah Medical University, Lahore, Pakistan; zahida_opetsurge@gmail.com

*             Correspondence: ahmadtayyaba2@gmail.com

Abstract: Suicide is a complex phenomenon which involves social, cultural, biological, psychological and environmental factors. Pakistan is a low income Muslim country, in which suicide cases have increased in recent years. Our review focuses on the causes of suicide in Pakistan. A systematic review was done to find out about the causes of suicide in Pakistan. Databases like PubMed, Google Scholar, Science Direct were searched using keywords like “suicide”, “suicide attempt”, “etiology”, “causes”, “Pakistan”. Total of 208 articles were screened out of which only 7 met our inclusion criteria. The rest were excluded because data wasn’t of Pakistan or wasn’t just limited to Pakistan, Qualitative data was extracted out of these articles and was tabulated and exposed the major causes of suicide in Pakistan. Systematic review was conducted to find out about the causes of suicide in different age groups, genders and regional groups. Majority suicides were linked to domestic problems. Most suicide attempts were done by females, married people and youth, indicating the strong association of gender bias, family disputes and depression, with suicide. Mental health problems, unemployment and prolonged illnesses and low income also contributed a great deal to suicide. Other causes like social injustice, failure in love, failure in exams, bullying and sexual abuse were also there. There is a need for greater attention and in-depth studies to elaborate on causative mechanisms for these public health issues. The most common reasons that compel an individual to take his/her own life are depression/mental illness, socioeconomic conditions, domestic violence and disputes, unemployment and some major failure in life.

Keywords: suicide, Pakistan, youngsters, aetiology

  1. INTRODUCTION

Suicide is a behavior that results in death or several losses that are the immediate or final outcome. It is an act of harming oneself voluntarily and intentionally. Suicidal ideation is characterized as suicidal ideas. Suicidal thoughts are oft en referred to as thoughts of injuring or killing oneself .According to tradition, there are three Suicidal terms that include suicidal ideas, attempts and successful suicides. Suicidal ideation refers to delusional ideas, self-harm, the preparation for suicide, and there is yet, a strong connection between intention and action [1]. Suicide attempts and suicide are among the major causes of morbidity and mortality worldwide. Suicide exposure has been related to an increased risk of physical sickness and adverse mental illness such as depression [2]. Several other factors are also related to suicide such as alcohol and drug abuse, social media effects, poor lifestyle, low income, high expenses, unemployment, study burden, academic stress, lack of education, lack of social support due to toxic relationships, toxic friends and abusive parents and teachers. Therefore this phenomenon should be understood from a multifactorial perspective [3] .Many studies showed that suicide rates are greater in males but suicidal attempts are higher in females. Adults with previous self-injurious thoughts and behavior have high risk of dying than older age [4].  Pakistan is a low income, agricultural country whose 70% population lives in rural areas and one third lives below the poverty line [5]. So, low socioeconomic status, low qualification and unemployment have been among the leading causes of complete suicide attempts in Pakistan [5, 6]. Other major causes include familial disharmony, domestic violence, gender inequality, personal issues and emotional problems [7, 8]. Social isolation, and aggravation of existing anxiety disorders, mood disturbances from COVID-19 or previous psychological history and chronic illnesses have been reported to have been the causative factors for suicides in Pakistan [9, 10]. In addition to it, childhood trauma, sexual violence, cognitive distortions, personality traits and previous unsuccessful attempts have also been indicated to play a part in to why people commit suicides. Previous studies have revealed that Pakistan lacks certified data about suicide mortality as no statistical analysis about suicidal ideation and successful attempts is done on national level [5]. There has been seen a rise in complete suicidal attempts among students. Academic pressure, failure to reach a goal and untreated psychiatric illnesses are most likely the causative factors for suicide in students. Literature lacks enough data for timely measures to be undertaken to prevent these incidents. Data specifying gender associated suicides in Pakistan is also scarce, that poses as a potential research gap for the studies in future. This study aims to identify association of above mentioned causative factors with suicidal attempts. A better understanding of their effects on suicidal ideation and attempts can help formulate cost-effective interventions. Prevention programs that target young people, females, and low socioeconomic groups, and aim to reduce harmful alcohol use, can help prevent suicides.

  1. MATERIALS AND METHODS

A systematic review was done to find out about the causes of suicide in Pakistan. Databases like PubMed, Google Scholar, Science Direct were searched using keywords like “suicide”, “suicide attempt”, “etiology”, “causes”, “Pakistan”. No filters in terms of time, study design, language, country of publication, etc. were used in order to retrieve all the available literature. Articles along with the references they included were searched to reach more articles. Identified studies were uploaded in Mendeley Library and duplicates were removed. Initially, the articles were screened on the basis of title and then abstract, after which the full text articles were screened. Total of 113 articles were screened out of which only 7 met our inclusion criteria. The rest were excluded because data wasn’t of Pakistan or wasn’t just limited to Pakistan. Qualitative data was extracted out of these articles and was tabulated and exposed the major causes of suicide in Pakistan. Inclusion Criteria: Cross-sectional studies, case-control studies, cohort studies, review articles, systematic reviews and original articles encompassing suicidal behavior, suicidal ideation, attempted and complete suicides were included. Only English articles were added. Exclusion Criteria: All non-English articles, non-peer reviewed literature, technical articles, newspaper columns and articles, letters, editorials, case reports and case series studying causative factors for suicides were excluded.

PRISMA Flow Chart

Figure 1: PRISMA Flow Chart

  1. RESULTS AND DISCUSSION

Seven studies were reviewed to find out major causes of suicide and suicidal ideation in Pakistan. Across Four studies there was evidence that domestic violence and other domestic problems were associated with a significantly increased risk of suicide death [13-15, 17]. Three of these studies focused on general population of different samples from Pakistan while one study [17] focused particularly on females. Domestic problems were associated with upto 59% suicide cases in these studies [13].  In a survey conducted in Pakistan, 76.4% participants agreed that domestic problems were associated with increased risk of suicidal behavior [17]. Mental health problems or psychiatric illnesses were associated with increased risk of suicidal behaviors in six studies [11-13, 14, 16, 17]. The psychiatric problems included social pressure, depression, stress and psychopathologies. Three of these studies included general population of different samples from Pakistan, two studies focused particularly on females [16, 17] and one study focused on the teenage sample [11]. Individuals with depression stress and psychopathologies were at increased risk of suicidal behaviors. Mental disorders were associated with upto 35% suicide cases in these studies [14]. In a survey conducted in Chitral, Pakistan, 83.6% participants agreed that stress and depression were associated with increased risk of suicidal behaviour [17]. Three studies provided evidence of association of increased risk of suicidal behaviour with unemployment [11, 13, 14]. Two of these studies included general population of different samples from Pakistan [13, 14] and one study focused on the teenage sample [11]. Upto 22 cases of suicide in these studies were found to be due to unemployment [14]. Suffering from prolonged hopelessness, low self-esteem, obesity, diabetes, cancer or hypertension was found to be associated with increased risk of suicidal behaviours in two studies [11, 13]. One of these studies included general population of different samples from Pakistan [13] and one study focused on the teenage sample [11]. Up to 12 cases of suicide in these studies were found to be due to prolonged illnesses [13]. Low household income and financial problems were associated with increased risk of suicidal behaviours in six studies [11-15, 17]. One of these studies focused particularly on females [17] and one study focused on the teenage sample [11] while the others included general population of different samples from Pakistan. Financial problems were associated with upto 32.6% suicide cases in these studies [15]. In a survey conducted in Chitral, Pakistan, 70.9% participants agreed that stress and depression were associated with increased risk of suicidal behaviour [17]. Other causes of suicide and suicidal ideation include failure in love, failure in exams and fear of punishment [13]. Societal interference in success or failures of individuals was also associated with increased risk of suicide [14]. Bullying alongwith sexual and physical abuse was also found to be associated with increased risk of suicidal ideation [11]. A study conducted in Sindh also established a link of suicide with social injustice [16]. In our systematic review, we screened 208 journal articles and selected 7 articles which contained qualitative information about the causes of suicides in Pakistan. Muslim Shah et al. [11] reported that psychosocial stressors, low self-esteem and hopelessness, psychopathology like major depression disorder, biological factors like altered levels of neurotransmitters in brain, sexual and physical abuse, poverty, unemployment, bullying etc. are the major causes that can lead someone to decide to take his own life. It was also commented in this study that stress in home caused by authoritarian style of parents, negative family environment and less parental warmth are followed by low self-esteem and depression which eventually results in suicidal ideation and suicidal attempts. Muhammad Shahid et al. [12] mentioned that psychiatric disorders, gender bias, low socioeconomic status, interpersonal relationship problems, domestic disputes, poverty, unemployment, corruption, human rights violation, denial of justice, discrimination, violence and loosening of cohesion in society, are the leading causes that can lead to increased prevalence of suicide.  In the study done by S. Haroon Ahmed et al. [13], domestic troubles, mental disorders, prolonged illness, and unemployment are statistically proven to be the frequent causes of suicide in Pakistan, especially Karachi. It is also said that domestic troubles and failure in love are also included in the causes leading to suicide. Like Muhammad Shahid et al. [12], S.Haroon Ahmed et al. also stated that suicides are more prevalent in females and young people which leads to the need of more research and statistical data to figure out the facts. M.N. Tahir et al. [14] mentioned in their study that depression/mental illness, socioeconomic conditions, domestic violence, unemployment and major failure in life were the major reasons for attempting suicide in Mianwali, one of the cities of Pakistan. Students, unemployed and laborers were the most common occupations in which suicides prevailed. They also commented on the fact that 80% of the people with mental disorders ultimately committing suicide reside in lower and middle income countries like Pakistan. In their study, Bibi Rahnuma et al. [15] stated that domestic issues like family pressure, joint family problems , intra-marital problems,etc.,financial problems, mental disorders, societal interference in success or failures of individuals, difference of class and social status among people are the most potent causes of suicides in the beautiful region of Pakistan, Gilgit Baltistan. Looking deep in their study revealed that all of these causes are more or less common to the rest of the cities and regions of Pakistan. Shabana Tunio et al. [16] revealed in their study that social injustice, failure in love, mental illness, isolation, poverty, domestic violence, abuse including emotional and physical violence, illiteracy or lack of education, ill health condition, and tough family environment leading to intra family disputes were the most likely causes provoking people to take their own lives. They also stated that poverty and failure in love were the most common reasons among females of Nangarpaker, District Tharparker to commit suicide and other failure in love. It led them to recommend that suicide must be recognized as a major social issue, and more work needed to be done on this, especially suicide among females. Rukhsana Bibi et al. [17] mentioned that freedom of choice for male ignorance of parents with regards to children feelings, family dispute terming female suicide on accident, and patriarchal family system leads towards suicide. Family disputes, depression, social pressure, high stress, non-compliance of family, poor socioeconomic condition, unemployment, loss of jobs and aggression associated with it, are significantly related to increasing rate of suicides and hence steps needed to be taken to reduce the number of deaths caused by it. Similar to the studies in our systematic review, Angus M Kim et al., [18] also mentioned that depression and anxiety, work related problems like loss of jobs and unemployment, family issues, intra-marital and relationship issues, finanacial problems and sexual/physical abuse are included in the factors involved in the causation of suicides. The results of our study are similar to those of Massimiliano Beghi et al.’s [19] study, which found that male sex, aggressive self-harm techniques, any psychiatric disorder (such as depression, anxiety, or bipolar disorders), poor health, stressors or loss, and living alone appeared to be more significant for predicting completed suicides in late life. Responses to the questions posed by this quality rating scale were provided, and studies were graded while taking into account the various study designs. Four studies were classified as high quality, two as moderate, and one as low quality based on the score. It suggests that when it comes to producing data for guidelines, the overall caliber of this systematic review will be exceptional. The GRADE or RoB scales cannot be used to assess bias risk since the study designs used in these systematic reviews differed. Furthermore, the literature search yielded no cohort studies or randomized control studies, suggesting that additional research is necessary to assess and address the risk of bias and that there is a dearth of high-quality evidence about the causes of suicides in Pakistan. One of the strengths of this systematic review is the rigorous approach employed, which was completed in accordance with a published procedure. The approach to the search was thorough and well-thought-out. A number of significant insights were revealed by the theme synthesis of the literature, which also permits various recommendations for more study. To properly answer this crucial subject, further contextual and longitudinal qualitative research on the causes of suicide in Pakistan is required. Just a small portion of each article was used for the review itself, and very few of the papers specifically examined the reasons behind suicide in Pakistan. Furthermore, it was challenging to concentrate primarily on the goal of this systematic review because so few research looked explicitly into the reasons of suicides and also covered other elements including regional, religious, and legal repercussions.

  1. CONCLUSION

Suicide is not just a sociocultural phenomenon; in Pakistan, suicide should be viewed as a serious health issue. The most frequent causes of suicide attempts are mental illness or depression, financial hardships, spousal abuse and conflict, joblessness, and significant life setbacks. Other contributing factors include bullying, intramarital issues, gender bias, and social meddling in people’s successes or failures. The government must prioritize ending domestic abuse, poverty, and education in order to reduce the suicide rate. Research should be done on improving the role of emergency medical departments and providing quick access to healthcare in an emergency. To obtain reliable results, further study and data reporting on suicide are required.

REFERENCES

  1. Rahnuma B,Fangtong J,Khan M et al.Causes of suicide In Gilgit Baltistan Region.(European Academic Research , 2017.
  2. DeVylder JE, Lukens EP, Link BG, Lieberman JA. Suicidal ideation and suicide attempts among adults with psychotic experiences: data from the Collaborative Psychiatric Epidemiology Surveys. JAMA Psychiatry. 2015;72(3):219-225. doi:10.1001/jamapsychiatry.2014.2663
  3. Kim AM, Jeon SW, Cho SJ, Shin YC, Park JH. Comparison of the factors for suicidal ideation and suicide attempt: a comprehensive examination of stress, view of life, mental health, and alcohol use. Asian J Psychiatr. 2021;65:102844. doi:10.1016/j.ajp.2021.102844
  4. Castellví P, Lucas-Romero E, Miranda-Mendizábal A, et al. Longitudinal association between self-injurious thoughts and behaviors and suicidal behavior in adolescents and young adults: A systematic review with meta-analysis. J Affect Disord. 2017;215:37-48. doi:10.1016/j.jad.2017.03.035
  5. Khan MM, Naqvi H, Thaver D, Prince M. Epidemiology of suicide in Pakistan: determining rates in six cities. Arch Suicide Res. 2008;12(2):155-160. doi:10.1080/13811110701857517
  6. Shekhani, S.S., Perveen, S., Hashmi, DeS. et al. Suicide and deliberate self-harm in Pakistan: a scoping review. BMC Psychiatry 18, 44 (2018). https://doi.org/10.1186/s12888-017-1586-6
  7. Khan MM. Suicide prevention in Pakistan: an impossible challenge?. J Pak Med Assoc. 2007;57(10):478-480
  8. Pooja F, Chhabria P, Kumar P, et al. Frequency of Psychiatric Disorders in Suicide Attempters: A Cross-Sectional Study from Low-Income Country. Cureus. 2021;13(4):e14669. Published 2021 Apr 24. doi:10.7759/cureus.14669
  9. Qin P, Hawton K, Mortensen PB, Webb R. Combined effects of physical illness and comorbid psychiatric disorder on risk of suicide in a national population study. Br J Psychiatry. 2014;204(6):430-435. doi:10.1192/bjp.bp.113.128785
  10. Marie Diack & Derak Stewart. Development of Cardiovascular Abnormalities Because of Periodontitis in Nepali Population. Dinkum Journal of Medical Innovations, 1(01):27-30.
  11. Peter John, Irina Yang & Aparna Goel. A Systematic Literature Review of Importance of Emotional Competence in Healthcare Management. Dinkum Journal of Medical Innovations, 1(01):19-26.
  12. Nida Ishfaq & Yang Chan. An Analysis of Nutritional Awareness among Diabetic Patients. Dinkum Journal of Medical Innovations, 1(01):13-18.
  13. Humza Sohail, Markus Peter Chan & Umaima Nagari. Myocarditis after receiving the Covid-19 Vaccine in an Enormous Medical Facility. Dinkum Journal of Medical Innovations, 1(01):07-12.
  14. Naseem Jamil, Tahir Shamsi & Sara Gill. Literature Review on the Efficiency of Planter Fascia Stretching with Myofascial Release Technique. Dinkum Journal of Medical Innovations, 1(01):01-06.
  15. Rahnuma, Bibi & Fangtong, Ji & Khan, Masood & Saddique, Kamran & Ahmad, Intikhab & Khan, Ali. (2017). Causes of Suicide in Gilgit-Baltistan Region Causes of Suicide in Gilgit-Baltistan Region. European Academic Research. V. 4041-4051.
  16. Tunio, Shabana & Shouakt, Ghazala & Khan, Muhammad. (2021). Sociological Analysis of Suicide among Female: A Study of Nangarparkar, District Tharparker, Sindh. Liberal Arts and Social Sciences International Journal (LASSIJ). 3. 10.47264/idea.lassij/3.2.13.
  17. Bibi, Rukhsana & Khan, Younas & Shah, Mussawar. (2019). EXPLORING THE SOCIAL DETERMINANTS OF FEMALE SUICIDE IN DISTRICT CHITRAL, PAKISTAN. 2523-1227.
  18. Kim AM, Jeon SW, Cho SJ, Shin YC, Park JH. Comparison of the factors for suicidal ideation and suicide attempt: a comprehensive examination of stress, view of life, mental health, and alcohol use. Asian J Psychiatr. 2021;65:102844. doi:10.1016/j.ajp.2021.102844.
  19. Beghi M, Butera E, Cerri CG, et al. Suicidal behaviour in older age: A systematic review of risk factors associated to suicide attempts and completed suicides. Neurosci Biobehav Rev. 2021;127:193-211. doi:10.1016/j.neubiorev.2021.04.011

Publication History

Submitted: December 02, 2022
Accepted: December 20, 2022
Published: January 01, 2023

Identification

D-0095

Citation

Tahira Amanat, Umm-e-Aiman, Tayyaba Firdus & Zahida Bukhari (2023). A Systematic Literature Review on Suicidal Cases in Pakistan. Dinkum Journal of Medical Innovations, 2(01):12-17.

Copyright

© 2023 DJMI. All rights reserved