Risk Factors for Suicide in Bangladesh: Case–Control Psychological Autopsy Study S
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BJPsych Open (2021) 7, e18, 1–5. doi: 10.1192/bjo.2020.152 Risk factors for suicide in Bangladesh: case–control psychological autopsy study S. M. Yasir Arafat, M. A. Mohit, Mohammad S. I. Mullick, Russell Kabir and Murad M. Khan – – Background 6.48 48.59) for life events, 65.28 (95% CI, 0.75 5644.48) for pre- vious attempts and 12 (95% CI, 1.56–92.29) for sexual abuse. Suicide is an important, understudied public health problem in Bangladesh, where risk factors for suicide have not been inves- Conclusions tigated by case–control psychological autopsy study. The presence of a psychiatric disorder, immediate life events, previous suicidal attempts and sexual abuse were found as sig- Aims nificant risk factors for suicide in Dhaka, Bangladesh. To identify the major risk factors for suicide in Dhaka, Bangladesh. Keywords Risk factors; suicide; Bangladesh; case–control study; psycho- Methods logical autopsy. We designed a matched case–control psychological autopsy study. We conducted a semi-structured interview with the next- Copyright and usage of-kin of 100 individuals who died by suicide and 100 living © The Author(s), 2020. Published by Cambridge University Press controls, matched for age, gender and area of residence. The on behalf of the Royal College of Psychiatrists. This is an Open study was conducted from July 2019 to July 2020. Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/ Results licenses/by/4.0/), which permits unrestricted re-use, distribu- The odds ratios for the risk factors were 15.33 (95% CI, 4.76– tion, and reproduction in any medium, provided the original work 49.30) for the presence of a psychiatric disorder, 17.75 (95% CI, is properly cited. Suicide is a leading cause of death worldwide, and identifying risk strategy. Therefore, we aimed to identify the major risk factors for factors has been considered as the key initiative of suicide preven- suicide in Dhaka, Bangladesh. tion.1 It has been widely accepted that about 90% of people who – die by suicide suffer from at least one psychiatric disorder.1 3 Hence, the treatment of psychiatric disorders has been recom- – Method mended as an important prevention strategy.1 3 Bangladesh is a lower middle-income country in South-East Study design Asia, with a high density of population. Dhaka, the capital city, is – one of the fastest-growing megacities in the world, and is also the This was a matched case control psychological autopsy study largest city in Bangladesh. It has a population of over 20 million, conducted between July 2019 and July 2020. We conducted a with a density of about 23 234 people per square kilometer.4 face-to-face semi-structured interview with the next-of-kin of 100 Suicide is a neglected public health problem in Bangladesh. There purposively selected individuals who died by suicide and 100 is no national suicide surveillance system, dedicated suicide data- living controls, matched by age, gender and area of residence in base or national suicide prevention strategy.5 There is a wide vari- Dhaka city. ation of suicide rates between different studies and the World Health Organization (WHO) suicide data. As per the WHO report of 2014, the global suicide rate was 7.8 per 100 000 popula- Suicide cases tion in both genders, whereas it was 8.7 per 100 000 population in A list of suicide cases with contact details of the deceased (family females and 6.8 per 100 000 population in males in 2012 in members, witnesses and police) was obtained from the Bangladesh.5 This female predominance has also been revealed by Department of Forensic Medicine and Toxicology, Dhaka Medical other studies, although the rate varies widely.5 Furthermore, there College, and Shaheed Suhrawardy Medical College, Dhaka. The is a strong likelihood of underreporting of suicidal events in the list of cases that were confirmed as suicide after medico-legal country. All suicide events are supposed to be reported to the autopsy between January 2019 and February 2020 was collected. police, and the legal authority gives the verdict of suicide. We contacted the relatives of 358 individuals who died by suicide, Risk factors for suicide have not been studied systematically in to complete the 100 interviews. From the collected list we inter- Bangladesh. The few studies that have been carried out show differ- viewed the next of kin, and those who agreed to talk with us pro- ent sociodemographic and risk factors compared with Western vided informed written consent. The response rate was 27.93%. countries.5 Female gender, age <30 years and immediate emotion- The response rate was lower for several reasons: in some cases, ally charged events, rather than mental disorders, have been family members were not living in Dhaka (n = 53, 14.8%); next- reported as risk factors in the country.5,6 As a result, few and spor- of-kin could not always be traced (n = 38, 10.6%); some respondents adic suicide prevention activities have been initiated, with no central did not want to talk about the matter (98, 27.4%) and in some cases, strategy or harmonisation.7 With this background, there is an the individual’s address could not be traced (n = 69, 19.3%). Stigma, immediate and unmet need to determine the risk factors for misinformation and fear of legal and social harassment could be suicide in Bangladesh, to formulate a national suicide prevention reasons for uncooperativeness in the interviews. 1 Downloaded from https://www.cambridge.org/core. 26 Sep 2021 at 18:16:56, subject to the Cambridge Core terms of use. Arafat et al Controls sexual assault and rape, along with its social consequences, as sexual Age (±2 years), gender and area of residence were matched between harassment. cases and controls. The controls were from a close neighbourhood of 25 houses in the same street. The next street was searched if we Interview techniques did not get an appropriate control from the same street. The con- Initial contact was made over the mobile phone with the family trols were not present during the interview. We faced similar diffi- members of the person who had died by suicide. Once the contact culties in interviewing the next-of-kin of the controls as we faced in was made, study objectives and processes were discussed in a cultur- the cases. We had to approach 409 prospective controls to complete ally appropriate manner, and an appointment to visit the house was 100 interviews. The response rate was 24.44%. sought. Then, the visit to the house was performed and a face-to- face semi-structured interview was conducted. A total of nine (four cases, five controls) next-of-kin visited the office of the first Instruments author. In several cases, the interview was conducted in front of a We adopted the instrument used in the Karachi Suicide Study8 for local journalist (n = 7), local leaders (n = 5) and police (n = 2). studying the demographic variables of the cases/controls and infor- Many times, several family members (n = 65) were present. The mants, past psychiatric history, medical history, psychiatric history key informants were parents (43 cases, 49 controls), spouses (24 of first-degree relatives, details of previous attempts of self-harm, cases, 31 controls), siblings (10 cases, 4 controls), second-degree details of the suicide, educational attainment and work conditions, relatives (10 cases, 2 controls), children (5 cases, 7 controls), social network and relationship issues, perceived key factors and acquaintances (6 cases, 6 controls) and others (betrothed, profes- principal ways of prevention of individual cases, and details of the sionals (2 cases, 1 control)). The primary informant was noted as interview.8 the responders. However, information was collected, checked and Psychiatric illness was investigated with the Structured Clinical verified from as many respondents as possible. All interviews Interview for DSM-IV Axis I Disorders (SCID-I).9 A detailed treat- were conducted by the first author. The timing of the interview ment history was recorded. The Structured Clinical Interview for ranged from 6 weeks to 6 months after the suicide. A typical inter- DSM-IV Personality Disorders (SCID-II) was used to identify per- view took 1.5–2 h for the cases and 1–1.5 h for the controls. sonality disorders.10 The SCID-II was used because of a lack of a standard, culturally validated instrument to diagnose personality Statistical analysis disorder. Moreover, the interview was conducted by a psychiatrist and SCID-I was used for axis I diagnosis, which ensures the use For the statistical analysis, we used IBM SPSS version 27 for of instruments from the same classification system of mental disor- Windows and Microsoft Excel version 2010. A significance level P ders. Life events during the past 2 days, month and year were iden- of < 0.05 was considered statistically significant. Continuous vari- tified.11,12 Life events were taken from Paykel’s Life Events ables were presented as mean ± s.d. Demography and psychiatric Schedule.13 We also added some significant life events that were diagnoses were presented as frequency and percentages. The not listed in the schedule (e.g. sexual harassment), but are consid- dependent variable was the case (suicide) or control status, and ered significant in Bangladesh. We considered eve-teasing, indecent independent variables were assumed risk factors. Univariate condi- tional logistic regression analysis was performed to extract the matched odds ratios and their 95% confidence intervals. Table 1 Demography of cases and controls Cases Controls χ2, P-value Ethics statement Age group, years The study was conducted in accordance with the ethical standards 8–20 41 37 χ2 = 0.82 21–30 33 36 P = 0.91 of the Helsinki Declaration of 1975, as revised in 2008.