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Suicide in Central Asia Suicidology Online 2020; VOL. 11:1 ISSN 2078-5488 Systematic Review Suicide in Central Asia Shahnaz Savani ,1, Robin Edward Gearing 2, Yuri Frantsuz 3, Maria Sozinova 3 1 University of Houston-Downtown, Department of Criminal Justice and Social Work, Houston, Texas, USA 2 University of Houston, Houston, Texas, USA 3 St. Petersburg University of Humanities and Social Sciences, St. Petersburg, Russia Submitted: April 16th, 2019; Accepted: September 17th, 2019; Published: March 19th, 2020 Abstract: Nearly 1.5 million people die by suicide each year globally. Most suicides occur in Asia, yet research has predominately studied suicide in the West. Suicide in Central Asia is under researched. A systematic review of the current state of literature on suicide and suicidal behavior in Central Asia is needed. The study aims to 1) examine risk and protective factors for suicide in the five Central Asian countries; 2) identify prevalence data on suicides in these countries; 3) assess treatments available for suicide prevention and intervention. Four electronic databases (PsycINFO, MEDLINE, CINAHL, and SocINDEX) were searched across 30 years between 1987 and 2016 to identify studies that reported quantitative or qualitative data on suicide in Central Asia. A total of 15 studies were included in this review. A total of 31 risk factors and 15 protective factors were identified. Core risk and protective factors identified can facilitate the development and adaptation of evidence-based interventions in this under-investigated region. A clear limitation of the study is the quality and quantity of the research available on suicide in Central Asia. Keywords: Suicide; Central Asia; Kazakhstan; Kyrgyzstan; Tajikistan; Turkmenistan; Uzbekistan Copyrights belong to the Author(s). Suicidology Online (SOL) is a peer-reviewed open-access journal publishing under the Creative Commons Licence 4.0. Suicide is a serious and complex problem facing the about the quality and accuracy of suicide world. Annually, about 800,000 individuals die by information across the countries in Asia and suicide (Tandon & Nathani, 2018), 10-20 million generally accepted that reported national suicide attempt it, and 50-120 million are affected by the rates are unreliable (Tollfsen et al., 2012). suicide of a relative or friend (Beautrais, 2006). Consequently, this gap in research has limited the Suicide and self-harm comprise 1.47% of the Global investigation of suicide prevention and treatment in Burden of Disease (GBD) and contribute to 22.5 the five Central Asian countries which include million Years of Life Lost (YLL) to premature mortality Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan (Patel, Chisholm, Parikh, Charlson, Degenhardt, Dua and Uzbekistan. et al., 2016). Psychological autopsies demonstrate mental illness No single factor or cause explains suicide, it is a to be a major contributing factor for suicide complex outcome of biological, psychological, social, (Arsenault-Lapierre, Kim, Turecki, 2004). In the environmental, and cultural factors (Alonzo & western context, mental illness is reported to be a Gearing, 2018). Almost two-thirds of all suicides contributing factor to a majority of suicides. But in occur in Asia (Tandon & Nathani, 2018); while the the context of low and middle income countries the majority of suicide research occurs in Western and influence of this factor in less pronounced (Patel, developed countries. Further, there is suspicion Chisholm, Parikh, Charlson, Degenhardt, Dua et al., 2016). In many Asian countries, suicide is often considered to be more of a social phenomenon Shahnaz Savani, LMSW, M.A rather than an individual act (Goldsmith et al., 2002). Address: One Main Street, C-345, Houston, TX 77002 E-mail: [email protected] Consequently, socio-economic issues, familial issues, 1 Suicidology Online 2020; VOL. 11:1 ISSN 2078-5488 oppression and gender based violence, and other Methods cultural factors appear to have a greater role in suicide. Four electronic databases (PsycINFO, MEDLINE, The five republics in Central Asia became CINAHL, and SocINDEX) were searched across 30 independent following the dissolution of the former years between 1987 and 2016 to identify studies that USSR in 1991. The countries are going through reported quantitative or qualitative data on suicide severe growing pains as they continue to adjust to in Central Asia (see Figure 1). The Boolean search reality in a post-Soviet era (Ruffin, 1999). The rapid strategy matched the following criteria: (1) Central shift in economic, governmental and social-political Asia or Kazakhstan or Kyrgyzstan or Tajikistan or philosophy, and the resulting unrest have further Turkmenistan or Uzbekistan; (2) suicid* or self- exacerbated the gaps in the countries’ ability to see immolation or aintihar (Arabic for suicide) or to the basic needs of its citizenry, such as primary samoubiystvo (Russian for suicide); (3) published in health care, satisfactory education, sufficient jobs the English or Russian languages; and (4) published and income (Hegland, 2010). The Central Asian as peer-reviewed. Exclusion criteria included: (1) governments are burdened by the challenges studies that did not specifically include suicide, inherited from the past Soviet system, existing suicide attempts, or suicide ideation; (2) studies on corruption, limited resources, and weak suicide conducted exclusively outside of the infrastructure (Ruffin, 1999). In addition, this region identified Central Asian region; (3) review articles; has been managing with high rates of (4) theoretical articles; and (5) letters to the editor. unemployment, particularly among the youth, often resulting in increased levels of labor migration to Figure 1. Review and selection of articles. secure economic employment (Hegland, 2010). Nascent research in this area have highlighted a 44 articles identified and reviewed from electronic number of factors related to suicide among young databases people including economic hardship, interpersonal violence, migration and unmet basic needs (UNICEF, 13 articles removed for 2014). duplication In struggling to address the myriad of needs, governments in Central Asia have either demonstrated no clear or minimal effort to develop 31 articles included for further review systematic suicide prevention or intervention programs, or support research in this important area (Haarr, 2010). This lack of attention to suicide is not 13 articles removed based on uncommon to other low income countries with eligibility criteria 2 articles not found limited governmental and public resources available for this issue. Effective research on suicide ideation, behaviors (i.e., suicide attempts and completions), 15 articles included in Systematic Review and the prevalence of this phenomenon may support future governmental efforts to address suicide within their national borders and across the region. Thus, there is an urgent need to investigate suicide The systematic search identified 44 eligible studies, in this region. 13 articles in PsycINFO, 21 articles in MEDLINE, four This systematic review will lay the groundwork for articles in CINAHL, and six articles in SocINDEX. further research and intervention in this area. This Thirteen of these articles were duplicates and study aims to 1) examine risk and protective factors removed, and another two articles were removed as for suicide in these countries; 2) identify existing they could not be located. Of the 29 remaining prevalence data on suicides in the five Central Asian articles, 27 were in English and 2 were in Russian. The countries; and 3) assess treatments available for articles included in this review were assessed and suicide prevention and intervention. Through this coded by the research team comprised of English systematic review, core risk and protective factors and Russian researchers according to established have emerged that can facilitate the development criteria. Each eligible article was reviewed and coded and adaptation of evidence-based interventions in independently by two authors, SS and RG reviewed this under-investigated region. the English articles and YF and MS reviewed the Russian articles, resulting in a final inclusion of 15 articles in the systematic review. Coding was completed using a data abstraction form, developed to synthesize findings from all eligible peer-reviewed 2 Suicidology Online 2020; VOL. 11:1 ISSN 2078-5488 published studies. That data abstraction form was conflict, husband’s migration for economic reasons developed to systematically extract core study and poverty. Service related factors include lack of components (e.g., publication details, study design, access to help and inadequate support available sample); Central Asian country (e.g., Kazakhstan, particularly for women and families. Environmental Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan); factors included higher temperatures in the summer suicide focus (e.g., ideation, attempts, completions); months, exposure to radiation during the Chernobyl identified risk and protective factors; outcomes and incident and exposure to trauma during the civil wars findings; and any reported recommendations for in Central Asia. suicide treatment, services or future areas of research. Discrepancies in coding were resolved Results through discussion and consensus and used to inform and modify the data abstraction form. Data A total of 15 studies were included in the systematic abstractors’ maintained over 95% inter-rater review (see Table 1). Six studies (40%) were
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