Current challenges of suicide and future directions of management in Bangladesh: a systematic review

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Abstract

Objectives

Bangladesh is a densely populated country in south-east Asia with paucity of research in suicide. This systematic review was aimed at critical appraising various aspects of suicide in Bangladesh based on available literature and systematic search.

Methods

Extensive literature search was conducted in Scopus, PubMed, PubMed Central, Google, Google Scholar and BanglaJOL with searching key words without any date boundary and without any basis of types of studies, that is, all types of studies were scrutinised. The author focused on sources of suicide data along with epidemiological variables of suicides in Bangladesh such as suicide rate, gender of victims, methods of suicides, risk factors and prevention activities and role of media in suicide.

Results

After exclusion of repetitions, screening was performed, and finally, 35 articles were selected for review. Amongst the 35 articles, 16 articles were original contributions, 2 systematic reviews, 6 narrative reviews, 2 scoping reviews, 3 editorials, 3 case reports and rest correspondence article. The review revealed that the actual rate of suicide in Bangladesh is yet to come out and quality data is a real challenge. Women are dying more than the men, and early adulthood is the most vulnerable time of life.

Discussion

Suicide is a under attended problem in Bangladesh, as the country yet to reveal the actual rate of suicide along with the challenge of quality data. Prevention activities have been started but yet to be visualised. Decriminalisation of suicide in the legal criteria and establishment of suicide surveillance can be the top priorities in the country.

Abstract

Objectives

Bangladesh is a densely populated country in south-east Asia with paucity of research in suicide. This systematic review was aimed at critical appraising various aspects of suicide in Bangladesh based on available literature and systematic search.

Methods

Extensive literature search was conducted in Scopus, PubMed, PubMed Central, Google, Google Scholar and BanglaJOL with searching key words without any date boundary and without any basis of types of studies, that is, all types of studies were scrutinised. The author focused on sources of suicide data along with epidemiological variables of suicides in Bangladesh such as suicide rate, gender of victims, methods of suicides, risk factors and prevention activities and role of media in suicide.

Results

After exclusion of repetitions, screening was performed, and finally, 35 articles were selected for review. Amongst the 35 articles, 16 articles were original contributions, 2 systematic reviews, 6 narrative reviews, 2 scoping reviews, 3 editorials, 3 case reports and rest correspondence article. The review revealed that the actual rate of suicide in Bangladesh is yet to come out and quality data is a real challenge. Women are dying more than the men, and early adulthood is the most vulnerable time of life.

Discussion

Suicide is a under attended problem in Bangladesh, as the country yet to reveal the actual rate of suicide along with the challenge of quality data. Prevention activities have been started but yet to be visualised. Decriminalisation of suicide in the legal criteria and establishment of suicide surveillance can be the top priorities in the country.

Introduction

Bangladesh is a densely populated country in south-east Asia having about 160 million people with a density of about 1063 per square kilometre (Shahnaz et al. 2017; Arafat 2017; Mashreky et al. 2013). Suicide is a complex, multi-causal, global preventable public health problem that is under researched in Bangladesh (World Health Organization 2014; Shahnaz et al. 2017; Mashreky et al. 2013; Shah et al. 2017, 2018; Arafat et al. 2018a,b; Arafat 2017). The World Health Organization (WHO) estimated that about 10,000 persons are dying by suicide per year in the country (World Health Organization 2014; Mashreky et al. 2013; Shahnaz et al. 2017; Begum et al. 2017a). It is the fourth leading cause of overall injury-related deaths and second important cause of injury-associated death in age groups of 20–39 years in Bangladesh (Mashreky et al. 2013). However, national suicide surveillance and nationwide study on suicide are yet to be initiated (Khan 2005; Arafat 2017; Shah et al. 2017; Chowdhury et al. 2018). Furthermore, it is still a criminal offence in the legal system of the country, which has been considered as a barrier of help seeking (Suryadevara & Tandon 2018; Salam et al. 2017; Khan 2005; Arafat 2017; Shah et al. 2017). Therefore, the author aimed at critical appraising different aspects of suicide in Bangladesh based on the available literature and systematic search.

Methods

Literature searching

For the critical appraisal of suicide in Bangladesh, the author conducted a systematic review of the following databases: PubMed, PubMed Central, Scopus, Google, Google Scholar and BanglaJOL. The relevant literature search was conducted from August to October 2018. The search terms used were suicide in Bangladesh, rate of suicide in Bangladesh, methods of suicide in Bangladesh, risk factors of suicide in Bangladesh, epidemiology of suicide in Bangladesh and means of suicide in Bangladesh.

Selection of the articles

The author considered the following criteria for inclusion of articles in the review:

  • Articles discussing variables of suicides

  • Articles in English language

  • Articles of suicide of Bangladeshi citizens living in Bangladesh at the time of study

  • Articles of suicide covering the geography of Bangladesh only

The author considered the following criteria for exclusion from the review:

  • Articles discussing only self-harm

  • Articles discussing accidental poisoning

  • Articles revealing suicide as a minor by-product variable for overall cause of death in a community

Data extraction and assessment of bias

The extracted data included author names, publication year, type of article, sample size, study design, demography of respondents, quality of data, sources of suicide data, rate of suicide in Bangladesh, methods of suicide in the country, prominent risk factors of suicide, existing suicide prevention activities, assessment of media activity influencing the suicidality of people of Bangladesh and possible bias based on the PRISMA guideline by the author himself (Fig. 1). Biases were evaluated based on the Cochrane criteria (Higgins et al. 2017).

Figure 1

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Figure 1

Flow chart of article search and selection process

Citation: Global Psychiatry 2, 1; 10.2478/gp-2019-0001

Results

Outcome of the systematic search

A total of 1057 articles were identified from the systematic search using the above-mentioned search terms from PubMed, PubMed Central, Scopus, Google, Google Scholar and BanglaJOL after the exclusion of duplicates. Titles and abstracts of these papers were screened for their relevance on suicide metrics of Bangladesh. A total of 44 full-text articles were reviewed, and finally, 35 articles were included in the study following PRISMA guideline (Figure 1).

Data characteristics

Amongst the finally selected 35 articles, majority (16) were original contributions, followed by review articles as 2 were systematic reviews, 6 narrative reviews, 2 scoping reviews, 3 editorials and followed by the case reports (3) and rest were the correspondence/letter to the editor article (Table 1). The year of publication ranges from 2002 to 2018 with increased propensity of recent articles.

Table 1

List of Articles

SLAuthorPublication yearStudy designType of articleParticipantsTitleSummary
1Arafat et al.In pressCross-sectional and observationalOriginal320 news reportsQuality of online news reporting of suicidal behavior in Bangladesh against World Health Organization guidelinesAssessed the quality of online news reporting of Bangla news portal, which is the first study assessing the reporting quality against WHO guidelines
2ArafatIn pressObservationalCorrespondence (review)N/AFemales are dying more than males by suicide in BangladeshDiscussed the gender distribution of suicide in Bangladesh
3Arafat et al.2018bCross-sectional and observationalOriginal358Demography and risk factors of suicidal behavior in Bangladesh: A retrospective online news content analysisAssessed the demography and risk factors of suicide by analysing online media reports
4Arafat and Hossain2018ObservationalCorrespondence (Commentary)3Suicide during international sports events (football World Cup 2018)Discussed the suicidality during major sports events such as World Cup Football
5Arafat2018aObservationalCorrespondence (Commentary)N/ASuicide prevention activities in BangladeshDiscussed existing suicide prevention activities
6Shah et al.2018Cross-sectional and observationalOriginal56Demography and risk factor of suicidal behavior in Bangladesh: A cross-sectional observation from patients attending a suicide prevention clinic of BangladeshAnalysed the demography of patients of a suicide prevention clinic of Bangladesh
7Arafat2018bCase reportLetter to the Editor1Suicide by intravenous kerosene: A case report in BangladeshReported suicide by atypical means (intravenous kerosene)
8Shah et al.2017Cross-sectional and observationalOriginal271Demography and risk factors of suicide in Bangladesh: a six-month paper content analysisAssessed the demography and risk factors of suicide by analysing printed newspaper reports
9Salam et al.2017EpidemiologicalOriginal1,169,593The burden of suicide in rural Bangladesh: magnitude and risk factorsDiscussed the impact and risk factors of suicide in rural areas of Bangladesh
10Ahmed et al.2017Systematic reviewN/ASuicide and depression in the World Health Organization South-East Asia region: a systematic reviewDiscussed the prevalence of depression amongst the suicide victims
11Hasan et al.2016Case report1An unusual case of suicide attempt using intravenous injection of keroseneReported suicide by atypical means (intravenous kerosene)
12Jordan et al.2014Scoping reviewN/ASuicide in south Asia: a scoping reviewDiscussed different parameters of suicide
13Debnath et al.2014Case report1A case of acute insulin poisoning with attempt to suicideDiscussed suicide by atypical means (insulin)
14Masrekhy et al.2013EpidemiologicalOriginal819,429Suicide kills more than 10,000 people every year in BangladeshExplored the epidemiology of suicide in Bangladesh
15Halim et al.2010Cross-sectional and observationalOriginalVarious factors of attempted suicide in a selected area of Naogaon districtDiscussed the factors of attempted suicide in district of Bangladesh
16Quader et al.2010Cross-sectional and observationalOriginal1862Post mortem outcome of organophosphorus compound poisoning cases at Mymensingh Medical CollegeMentioned the postmortem finding of poisoning deaths
17Khan2002ReviewN/ASuicide on the Indian subcontinentReviewed the different parameters of suicide
18Wu et al.2012ReviewN/ASuicide methods in Asia: implications in suicide preventionDiscussed different parameters of epidemiology
19Knipe et al.2015Systematic reviewN/AAssociation of socio-economic position and suicide/attempted suicide in low- and middle-income countries in South and South-East Asia – a systematic reviewReviewed the association between socioeconomic status and suicidal behaviour
20Bachman2018ReviewN/AEpidemiology of suicide and the psychiatric perspectiveDiscussed the different parameters of epidemiology
21Suryadevara and Tandon2018EditorialN/ADecriminalization of Attempted Suicide across Asia- It Matters!Discussed the status and importance of decriminalization of suicide
22Tandon and Nathani2018EditorialN/AIncreasing suicide rates across Asia - a public health crisisDiscussed the recent data with the men-to-women ratio
23Khan2005ReviewN/ASuicide prevention and developing countriesDiscussed the suicide prevention status
24Feroz et al.2012Epidemiological surveyOriginal12,422A community survey on the prevalence of suicidal attempts and deaths in a selected rural area of BangladeshSurveyed the suicidal rate and epidemiology of suicide small area
25Reza et al.2013Case control and cross-sectionalOriginal230 (113 cases and 117 controls)Risk factors of suicide and parasuicide in rural BangladeshAnalysed the risk factors of suicide in Bangladesh
26Begum et al.2017aCross-sectional and observationalOriginal2,133Suicidal death due to hangingAssessed the suicidal deaths by hanging
27Arafat2017ReviewN/ASuicide in Bangladesh: a mini reviewReviewed the epidemiology of suicide in Bangladesh
28Shahnaz et al.2017Scoping reviewN/ASuicidal behaviour in Bangladesh: a scoping literature review and a proposed public health prevention modelReviewed the suicidal behaviour elaborately
29Ahmed and Hossain2010Cross-sectional and observationalOriginal145Hanging as a method of suicide: retrospective analysis of postmortem casesAnalysed the postmortem reports of hanging deaths
30Ali et al.2014Cross-sectional and observationalOriginal334Suicide by hanging: a study of 334 casesAnalysed the postmortem reports of hanging deaths
31Arafat et al.2018aCross-sectional and observationalOriginal121Psychiatric morbidities and risk factors of suicidal ideation among patients attending for psychiatric services at a tertiary teaching hospital in BangladeshDiscussed the psychiatric morbidities and risk factors amongst suicidal ideators
32Arafat and Kabir2017EditorialN/ASuicide prevention strategies: which one to consider?Discussed different strategies of suicide prevention
33Qusar et al.2009Cross-sectional and observationalOriginal44Psychiatric morbidity among suicide attempters Who needed ICU interventionDiscussed psychiatric morbidities among the attempters
34Begum et al.2017bCommunity- based cross- sectional surveyOriginal2,476Prevalence of suicide ideation among adolescents and young adults in rural BangladeshAssessed suicidal ideations among adolescents
35Chowdhury et al.2018ReviewN/ABans of WHO Class I pesticides in Bangladesh— suicide prevention without hampering agricultural outputDiscussed the effect of bans of pesticides on suicide

Risk of bias assessment

Potential risk of biases pertained in the studies as many of the selected studies were cross-sectional and observational in design along with editorials, case reports and correspondence articles those lacked meticulous methods (Table 1). Two studies analysed conveniently selected news reports of suicidal news (Shah et al. 2017; Arafat et al. 2018b) and one study analysed media reporting quality without assessing the epidemiological aspects of suicide (Arafat et al. in press). However, the included epidemiological studies (4) followed meticulous scientific methods and had representative samples (Salam et al. 2017; Mashreky et al. 2013; Feroz et al. 2012; Begum et al. 2017b). One cross-sectional study had representative sample size, which explored suicide deaths by hanging only as method (Begum et al. 2017a). No study included or excluded participants based on the specific risk factors.

Discussion

Challenges of quality data

Similar to other developing countries, getting quality and strict scientific data is a central challenge in Bangladesh because of lacking of suicide surveillance and national suicide database, consideration of suicide as a criminal offence, existing religious beliefs and enduring cultural practices (Khan 2002, 2005; Arafat 2017; Salam et al. 2017; Shah et al. 2017). Suicide surveillance has not been established, which is a prime obstacle to get regular enduring data on suicide (Arafat 2017). Reliable and meticulous source of suicide data is out of reach for the researchers, policy maker as well as other individuals. Moreover, as per the legal system, it is still a punishable criminal offence that generates a natural tendency to hide the suicides. Channelising suicide as accidental death is somewhat a common phenomenon to avoid the aversive legal consequences, because mostly people have been harassed by the legal agencies instead of getting trails for suicidal events. Sometimes, relatives claim suicides as homicides without any firm evidence and start legal proceedings. This is somewhat a common phenomenon when suicide happens in in-law’s residence. Owing to adequate understanding, knowledge people become paranoid towards others even without any clue. Religious factors play roles to hide suicides, as suicide is discouraged in Islam and about 90% of inhabitants of Bangladesh are Muslims. In addition, strong social stigma on suicide in families affects social status, social acceptance, nuptial events specially affecting the girls of the affected family and such (Shahnaz et al. 2017; Arafat 2017; Shah et al. 2017; Khan 2002). Sometimes patients with suicidal behaviour are referred to another hospital to avoid adverse hassles; those are not only the legal issues but also other unexplainable demands of the patient party such as they create threatening pressure on the medical staffs demanding undue certificates that the behaviour is imposed by persecutors. Every now and then guardians take their patients to such hospitals where they can avoid suicide register and hide it from legal system. Hence, suicide is grossly under-registered and getting quality data is a real challenge in Bangladesh (Khan 2002, 2005; World Health Organization 2014). Available information was mainly found in reports of police and other law enforcing agencies, forensic reports, media sources and limited other sources of reports such as hospitals, Thana and courts (Chowdhury et al. 2018; Arafat 2017; Shah et al. 2017; Quader et al. 2010).

Suicide rate

Suicide is grossly under reported and under registered in countries such as Bangladesh (Khan 2002 2005; World Health Organization 2014; Chowdhury et al. 2018; Shahnaz et al. 2017). Moreover, there is no suicidal database in the country to report suicide metrics to the global agencies and to contribute in the global suicide statistics (Shah et al. 2017; Arafat 2017; Chowdhury et al. 2018). WHO reported that the suicide rate for 2012 in Bangladesh was 7.8 per 100,000 population, 8.7 women per 100,000 population and 6.8 men 100,000 population (World Health Organization 2014), which seems to be quite low than the actual rate. Similar rate was noticed in 2003 in a cross-sectional study in which the rate was found as 7.3 per 100 000 per year (Chowdhury et al. 2018). However, according to Economic and Social Commission for Asia and the Pacific (ESCAP), the rate was found about 30 per 100,000 of young adults every year in rural Bangladesh (Ruzicka 1998 cited in Begum et al. 2017b). A community-based study conducted by Feroz et al. in 2012 revealed that the suicidal rate was 128.8 per 100,000 populations per year in a specific district of Bangladesh, which seems to be much higher than the actual rate (Feroz et al. 2012). Other few studies reported the rate as 39.6 per 100,000 populations per year (Table 2) (Feroz et al. 2012; Qusar et al. 2009; Wu et al. 2012). Suicides were happening more in rural areas of Bangladesh, especially in Chuadanga, Jenaidah, Kustia, Meherpur, Jashore and Chandpur (Chowdhury et al. 2018; Shahnaz et al. 2017; Arafat 2017; Feroz et al. 2012). The country needs further larger studies to identify the near actual rate of suicides.

Table 2

Suicide rate

SLAuthorPublication yearType of ArticleSuicide rate (per 100,000)
1WHO2014Report7.8
2Wu et al.2012Review39.6
3Feroz et al.2012Original128.8
4Qusar et al.2009Original39.6
5Begum et al.2017Original30
6Chowdhury et al.2018Review7.3

Women are dying more than men

Repeated researches revealed the reverse gender pattern in Bangladesh in which women are dying more than their men counterparts, although exact gender ratio is yet to reveal (Tandon & Nathani 2018; Bachmann 2018; Arafat in press). Similar pattern has been noticed in China also, where women are dying more (Tandon & Nathani 2018; Bachmann 2018). Moreover, other reviews revealed that the gender ratio is lower in overall sub-continent and the ratio as 0.43–0.83:1 in Bangladesh (Jordan et al. 2013; Arafat 2017; Shahnaz et al. 2017; Arafat in press). Others revealed the men-to-women ration as 0.80:1 (Tandon & Nathani 2018; Bachmann 2018). Various studies revealed women preponderance repeatedly, namely, 70% were women in the study conducted by Shah et al. (2018), 58% were women in the study conducted by Arafat et al. (2018a), 58% were women in the study conducted by Shah et al. (2017), 60% were women in Arafat et al. (2018b) study, 59% were women in Qusar et al. (2009) study, 74% were women in the community-based study by Feroz et al. (2012), 62% were women in Begum et al. (2017a) study and 55% were women in Mashreky et al. (2013) study (Arafat in press). The women’s dominance might be the effects of complex interactions between patriarchal societal structure, perceived self-status of women, passive gender role, lower educational attainment, adolescence marriage, having child in teenage, lower economic freedom, fewer freedom in partner choice and few other enduring socio-cultural factors (Arafat in press; Arafat 2017; Feroz et al. 2012; Reza et al. 2014).

Third decade of life was found as the most vulnerable period of life revealed by previous researches (Arafat in press). Early reviews revealed persons of 20–30 years persons are dying more (Khan 2002; Arafat 2017). Begum et al. (2017a) found that about 47% of respondents were between 21 and 30 years, Mashreky et al. found that the median age was 25 years, Shah et al. (2018) found that about 54% of the respondents were within 18–25 years, Arafat et al. (2018) found that about 60% of respondents were below 30 years of age, Shah et al. (2017) found that about 61% of the respondents were below 30 years of age, Feroz et al (2012) found that 43% of the respondents were between 20 and 29 years, Qusar et al. (2009) found that 75% of the suicide attempters were below 30 years of age (Arafat in press). The global trend of suicide based on the nuptiality found that single, unmarried persons have been dying, whereas more married persons have been dying by suicide in Bangladesh (Mashreky et al. 2013; Arafat 2017; Knipe et al. 2015; Ahmed & Hossain 2010; Ali et al. 2014).

Methods of suicide

Choice of method of suicide is affected by intricated interaction of factors such as culture, religion, gender, personal belief, occupation, educational status, age and other related factors (Arafat 2018b; Arafat 2017). Hanging and poisoning are the common methods of suicide with recent trends of hanging prominence. A study from data of Bangladesh Police Statistics Department between 1996 and 2014 revealed that intentional pesticide self-poisoning was the most common cause (37.1%) of suicide, followed by hanging (30.5%) (Chowdhury et al., 2018). However, the authors mentioned that the trend of suicidal deaths by poisoning has been reducing and suicides by hanging have been increasing (Chowdhury et al. 2018). Another recent review found that intentional poisoning was the most common method followed by hanging in both gender (Shahnaz et al. 2017). One more study involving 61 respondents found that intentional poisoning was the most common method (62% (38) of the respondents), followed by hanging (31%) (Mashreky et al. 2013); another study found poisoning as the most common method (77.5%) (Halim et al. 2010). A study conducted in rural areas of Bangladesh found hanging as the most common method (59%), followed by poisoning (31%) (Table 3) (Salam et al. 2017). Study from suicide prevention clinic of 83 attempts found hanging as the commonest method (47%), followed by intentional poisoning (37%) (Shah et al. 2018). Another clinical study of 47 respondents with suicidal ideation revealed hanging as the commonest preferable method (55%), followed by poisoning (19%) (Arafat et al. 2018a). Study analysing the newspaper contents of 271 suicides found hanging in about 82% cases, followed by poisoning in about 8% of the cases (Shah et al. 2017). One more study that analysed 358 reports of online news portal found hanging in 61% of the reports, followed by poisoning in about 13% of the respondents (Arafat et al. 2018b). Another study of 44 intensive care unit admitted patients after suicidal attempts found poisoning as the commonest method (Qusar et al. 2009). Other methods are burning, drowning, jumping in front of train, fall from height, firearms, electric shock and cut injury (Salam et al. 2017; Shah et al. 2018, 2017; Arafat et al. 2018a,b). Atypical methods also noticed in the country such as intravenous kerosene (Hasan et al. 2016; Arafat 2018b) and intravenous insulin (Debnath et al. 2014).

Table 3

Methods of suicide

SLAuthorPublication yearType of ArticleSample sizeFirst methodSecond method
1Arafat et al.2018bOriginal358Hanging (61%)Poisoning (13%)
2Shah et al.2018Original83Hanging (47%)Poisoning (37%)
3Shah et al.2017Original271Hanging (82%)Poisoning (8%)
4Salam et al.2017Original38Hanging (59%)Poisoning (31%)
5Masrekhy et al.2013Original61Poisoning (62%)Hanging (31%)
6Shahnaz et al.2017ReviewPoisoningHanging
7Arafat et al.2018aOriginal47Hanging (55%)Poisoning (19%)
8Qusar et al.2009Original44Poisoning and overdose (95%)Hanging (5%)
9Chowdhury et al.2018Review311 208Poisoning (37%)Hanging (30.5%)
10Halim et al.2010OriginalPoisoning (77.5%)

Risk factors and preventive initiatives

Multiple studies revealed somewhat similar risk factors in Bangladesh. In 2012, a community-based study conducted by Feroz et al. found about 63% of suicides were proximally related with emotional events noticed within the family (Feroz et al. 2012; Shahnaz et al. 2017). Another study conducted in rural area revealed about 65.5% of suicides were related with emotional factors and again the factors were found within the family (Reza et al. 2013). A recent review mentioned other risk factors obtained from studies in which more than half of the suicides (51% and 57%) were related to emotional factors that were prevailed within the family (Shahnaz et al. 2017). Another review unveiled that the most common risk factor of suicide was marital discord followed by quarrel amongst the family members (Arafat 2017). A study analysing the newspaper contents found that about two-thirds of the risk factors were found within the family, mostly, marital discord followed by discord with family members (Shah et al. 2017). Another study that assessed online media portals found emotional risk factors as major issues, that is, affair-related issues were mentioned in about 14%, marital and familial discord in about 22% of suicides (Arafat et al. 2018a). A study assessing the decisive moment revealed that about 81% of the attempts were happened impulsively (Arafat et al. 2018b). Besides, marital and family quarrel issue, few noticeable risk factors were reported, these were also driven by emotionally charged events. Suicide amongst supporters of favourite sports teams is also not so uncommon in the country (Arafat & Hossain 2018). Other reported risk factors were also related with strong emotions such as sexual harassment; failing in exam; not fulfilling immediate demand such as motor bike, bicycle, special dress in ceremonial occasions, special television channel watching and so on; extra-marital relationship issue; early marriage; death of partner; death of children; verbal abuse by teacher; love-affair-related complicacy; domestic violence; and divorce (Feroz et al. 2012; Reza et al. 2013; Shah et al. 2017; Arafat et al., 2018a). However, previous reviews revealed psychiatric morbidities are the vital issues in suicide as a risk factor globally. Repeated evidences stated that approximately 90% of persons who died by suicide had been suffering from not less than one mental illness, and depression has been considered as the main culprit disorder accounting about 60% of deaths (Malakouti et al. 2015; Mann et al. 2005). Conversely, psychiatric illness as a risk factor of suicide is under focused and has not been considering as an important risk factor in the country (Feroz et al. 2012; Arafat 2017; Qusar et al. 2009). Very few researchers studied mental illness as a risk factor and very few proportions of the risk factors were found in that domain (Qusar et al. 2009; Arafat 2017; Shah et al. 2017; Arafat et al. 2018a,b; Feroz et al. 2012; Reza et al. 2013). A systematic review revealed that only 7% of the suicide victims/attempters had depression (Ahmed et al. 2017). Amongst the patients admitted in intensive care unit after suicidal attempt, mental illness was reported in about 59% of the respondents (Qusar et al. 2009); another study found that it was about 6% (Arafat et al. 2018a). However, depression was found in about 26% of respondents as reported by another study (Arafat et al. 2018b). These variations can be accounted by considering multiple factors such as lack of adequate researches exploring the relationship with mental disorder and suicide, cultural and geographical variation of risk factors, religious beliefs, strong social closeness and overall educational status and might be new other issues those demand further research.

In spite of huge necessity, few activities have been started in the country to prevent suicides. Amongst them, suicide prevention clinic has been dealing with the clinical populations, whereas the crisis-releasing hotline (Kan Pete Roi) has been listening the distressed people, although these are inadequate (Arafat 2018a). A newly formulated society is yet to start any preventive activities. Available global evidences revealed numerous prevention strategies that have been tested and trusted as effective in preventing suicide (Zalsman et al. 2016; Mann et al. 2005). However, no single strategy has been found as universally effective and superior than others (Arafat and Kabir 2017). As a significant portion of risk factors are related with immediate emotionally charged events, Bangladesh should really look for strategies that can support the distressed person immediately. The available hotline (Arafat 2018a) can be an effective option to ventilate the emergencies; however, it is yet to be popularised in the country. Health promotional activities focusing to make aware the people conscious regarding moments of life can be fruitful. Further multilateral research is necessary to identify the risk factors and the relationship of risk factors with existing biopsychosocial aspect of suicide and to sort the perfect, culturally customised prevention strategy, ensuring the maximum utilisation of available resources.

Media and suicide in Bangladesh

Recent research has been coming out engaging the media in research in Bangladesh. Both print and online portals have been scrutinised in recent days in the country, Shah et al. (2017) scrutinised the printed paper contents to analyse the demography and risk factors of suicide. Arafat et al. (2018b) dissected suicide news published in online portals and looked for the demography and risk factor of suicide. The quality of published reports of the analysis revealed poor media reporting status, which was assessed against WHO guideline. The reporting status revealed poor quality when assessed against WHO suicide reporting guidelines in Bangla. Unnecessary details of the victims, methods, life events and mono-causal explanations were declared very frequently. Educational approaches were fundamentally absent (Arafat et al. in press).

Future directions

More research to explore the suicides in Bangladesh is a time-demanded issue to estimate suicide metrics with quality data. National suicide database and suicide surveillance is an important consideration for this huge population. Changes in the legal system to decriminalise suicide in the country should be considered as immediate priority, which has been already done in nearby Asian countries and many other developed countries (Arafat et al. in press; Suryadevara & Tandon 2018). Decriminalisation would help to destigmatise the problem, increase the proper help-seeking behaviours for suicidality and demolish the undue legal harassments. Finding out the appropriate prevention strategy for the country is an immediate necessity to formulate, initiate, implement and evaluate its effectiveness. Multisectoral collaboration within the country amongst clinicians, social scientist, researchers, funders, media professionals, social workers, voluntary organisations, non-governmental organisation, funders, government and/ or any organisation connected with suicidality in the country. International organisations should come forward to alleviate the grave situation on suicide in Bangladesh.

The review included only articles in English languages readily available on Internet search, which could exclude potential other articles. The author did not include the grey literatures for the review, which could exclude bunch of publications those published in the printed journals of Bangladesh. The list of articles was checked and cross-checked by the same author, which could be a source of bias. Inclusion and search of other databases could reveal more articles.

In spite of the limitations, current review critically discussed vital areas of suicide in Bangladesh. To the author’s best knowledge, this is the first systematic review analysing suicidal metrics in Bangladesh, which recommends the decriminalisation of suicide in the legal system of the country, establishment of national suicidal surveillance, national suicide databases and more multilateral collaboration on suicide research in Bangladesh.

Conclusions

Suicide is an under-attended problem in Bangladesh, where the actual rate is yet to come out and quality data is a real challenge. Women are dying more than the men, and early adulthood (20–30 years) is the most vulnerable time of life. Hanging and intentional poisoning are the prime methods of suicide with gradual decrease in poisoning. Majority of risk factors are prevailed within the family. Prevention activities have been started but yet to make footprints. Decriminalisation and suicide surveillance are the top priorities in the country.

Acknowledgements

None

Conflict of Interest None

Declaration of ethics Not applicable

Declaration of informed consent Not applicable.

Funding Self-funded.

Author’s contribution The author has the sole contribution in every step of the study.

References

  • Ahmed HU, Hossain MD, Aftab A, Soron TR, Alam MT, Chowdhury MWA, et al. Suicide and depression in the World Health Organization South-East Asia Region: a systematic review. WHO South East Asia J Public Health. 2017;6(1):60-66.

  • Ahmad M, MZ Hossain. Hanging as a method of suicide: Retrospective analysis of postmortem cases. JAFMC Bangladesh. 2010;6(2):37-39.

  • Ali E, Maksud M, Zubyra SJ, Hossain MS, Debnath PR, Alam A, et al. Suicide by hanging: a study of 334 cases. Bangladesh Med J. 2014;43(2):90-93.

  • Arafat SMY. Suicide in Bangladesh: A mini review. J Behav Health. 2017;6(1):66–69.

  • Arafat SMY. Suicide prevention activities in Bangladesh. Asian J Psychiatr. 2018a;36:38.

  • Arafat SMY. Females are dying more than males by suicide in Bangladesh. Asian J Psychiatr. in press

  • Arafat SMY. Suicide by intravenous kerosene: A case report in Bangladesh. Asian J Psychiatr. 2018b;33:126-127.Arafat SMY, Kabir R. Suicide prevention strategies: Which one to consider? South East Asia J Public Heal. 2017;7(1):1–5.

  • Arafat SMY, Hossain MS. Suicide during international sports events (football World Cup-2018). Asian J Psychiatr. 2018;36:9293.

  • Arafat SMY, AkterH, Mali B. Psychiatric morbidities and risk factors of suicidal ideation among patients attending for psychiatric services at a tertiary teaching hospital in Bangladesh. Asian J Psychiatr. 2018a;34:44–46.

  • Arafat SMY, Akter H, Mali B. Quality of online news reporting of suicidal behavior in Bangladesh against World Health Organization guidelines. Asian J Psychiatr. in press

  • Arafat SMY, Mali B, Akter H. Demography and risk factors of suicidal behavior in Bangladesh: A retrospective online news content analysis. Asian J Psychiatr. 2018b;36:96-99.

  • Bachmann S. Epidemiology of suicide and the psychiatric perspective. Int. J. Environ. Res. Public Health. 2018;15:1425

  • Begum A, Khan NT, Shafiuzzaman A, Shahid F, Anam AA, Ahmed KS, et al. Suicidal death due to hanging. Delta Med Coll J. 2017a;5:89–93.

  • Begum A, Rahman AKMF, Rahman A, Soares J, Khankeh HR, Macassa G. Prevalence of suicide ideation among adolescents and young adults in rural Bangladesh. Int J Mental Health. 2017b;46:177–187.

  • Chowdhury FR, Dewan G, Verma VR, Knipe DW, Isha IT, Faiz MA, et al. Bans of WHO class I pesticides in Bangladesh—suicide prevention without hampering agricultural output. Int J Epidemiol. 2018;47:175–184.

  • Debnath CR, Debnath MR, Alam MM, Moshwan MM. A case of acute insulin poisoning with attempt to suicide. Mymensingh Med J. 2014;23(4):800-802.

  • Feroz AHM, Islam SMN, Reza S, Rahman AKMM, Sen J, Mowla M, et al. A community survey on the prevalence of suicidal attempts and deaths in a selected rural area of Bangladesh. J Medicine. 2012;13:3-9.

  • Ghanbari B, Malakouti SK, Nojomi M, Alavi K, Khaleghparast S. Suicide prevention and follow-up services: a narrative review. Glob J Health Sci. 2016;8:145-153.

  • Halim KS, Khondker L, Wahab MA, Nargis F, Khan SI. Various factors of attempted suicide in a selected area of Naogaon district. Mymensingh Med J. 2010;19(2):244-249.

  • Higgins JPT, Altman DG. Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions version 5.1. The Cochrane Collaboration; 2017.Available: http://www.cochranehandbook.org/. Accessed 02 October 2018.

  • Jordans MJD, Kaufman A, Brenman NF, Adhikari RP, Luitel NP, Tol WA, et al. Suicide in south Asia: a scoping review. BMC Psychiatry. 2014;14:358.

  • Khan MM. Suicide prevention and developing countries. J R Soc Med. 2005;98:459–563.

  • Khan MM. Suicide on the Indian Subcontinent. Crisis. 2002;23:104– 107.

  • Knipe DW, Carroll R, Thomas KH, Pease A, Gunnell D, Metcalfe C. Association of socio-economic position and suicide/attempted suicide in low and middle income countries in South and South-East Asia - a systematic review. BMC Public Health. 2015;15:1055.

  • Mashreky SR, Rahman F, Rahman A. Suicide kills more than 10,000 people every year in Bangladesh. Arch Suicide Res. 2013;17:387–396.

  • Malakouti SK, Nojomi M, Poshtmashadi M, Shooshtari MH, Moghadam FM, Rahimi-Movaghar A, et al. Integrating a suicide prevention program into the primary health care network: A field trial study in Iran. Biomed Res Int. 2015;2015:9.

  • Mann J, Haas A, Mehlum L, Phillips M. Suicide Prevention Strategies. JAMA. 2005;294:2064-2074.

  • Quader M, Rahman MH, Kamal M, Ahmed AU, Saha SK. Post mortem outcome of organophosphorus compound poisoning cases at Mymensingh Medical College. Mymensingh Med J. 2010;19(2):170-172.

  • Qusar MS, Morshed NM, Azad AMK, Kader MA, Shams SF, Ahmed FM, et al. Psychiatric morbidity among suicide attempters who needed ICU intervention. Bangabandhu Sheikh Mujib Med University J. 2009;2:73–77.

  • Reza AS, Feroz AHM, Islam SN, Karim MN, Rabbani MG, Alam MS, et al. Risk factors of suicide and para suicide in rural Bangladesh. J Medicine.2014;14:123-129.

  • Ruzicka LT. Suicide in countries and areas of the ESCAP region. Asia-Pacific Population Journal.1998;13:55–74.

  • Shah MMA, Sajib MWH, Arafat SMY. Demography and risk factor of suicidal behavior in Bangladesh: A cross-sectional observation from patients attending a suicide prevention clinic of Bangladesh. Asian J Psychiatr. 2018;35:4–5.

  • Shah MMA, Ahmed S, Arafat SMY. Demography and risk factors of suicide in Bangladesh: A six-month paper content analysis. Psychiatry J.2017;2017:3047025.

  • Shahnaz A, Bagley C, Simkhada P, Kadri S. Suicidal behaviour in Bangladesh: A scoping literature review and a proposed public health prevention model. Open J Soc Sciences. 2017;5:254–282.

  • Salam SS, Alonge O, Islam M, Hoque D, Wadhwaniya S, UlBaset M, et al. The burden of suicide in rural Bangladesh: magnitude and risk factors. Int J Environ Res Public Health. 2017;14:1032.

  • Suryadevara U, Tandon R. Decriminalization of attempted suicide across Asia- it matters!. Asian J. Psychiatr. 2018;35:A2–A3.

  • Tandon R, Nathani MK. Increasing suicide rates across Asia- a public health crisis. Asian J Psychiatr. 2018;36:A2–A4.

  • World Health Organization. Preventing suicide: A global imperative. Geneva. 2014.http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/ [Accessed on 01 July 2018]

  • Wu KC, Chen YY, Yip PS. Suicide methods in Asia: implications in suicide prevention. Int J Environ Res Public Health. 2012;9(4):1135-1158.

  • Zalsman G, Hawton K, Wasserman D, van Heeringen K, Arensman E, Sarchiapone M, et al. Suicide prevention strategies revisited: 10year systematic review. Lancet Psychiatry.2016;3:646-659.

Ahmed HU, Hossain MD, Aftab A, Soron TR, Alam MT, Chowdhury MWA, et al. Suicide and depression in the World Health Organization South-East Asia Region: a systematic review. WHO South East Asia J Public Health. 2017;6(1):60-66.

Ahmad M, MZ Hossain. Hanging as a method of suicide: Retrospective analysis of postmortem cases. JAFMC Bangladesh. 2010;6(2):37-39.

Ali E, Maksud M, Zubyra SJ, Hossain MS, Debnath PR, Alam A, et al. Suicide by hanging: a study of 334 cases. Bangladesh Med J. 2014;43(2):90-93.

Arafat SMY. Suicide in Bangladesh: A mini review. J Behav Health. 2017;6(1):66–69.

Arafat SMY. Suicide prevention activities in Bangladesh. Asian J Psychiatr. 2018a;36:38.

Arafat SMY. Females are dying more than males by suicide in Bangladesh. Asian J Psychiatr. in press

Arafat SMY. Suicide by intravenous kerosene: A case report in Bangladesh. Asian J Psychiatr. 2018b;33:126-127.Arafat SMY, Kabir R. Suicide prevention strategies: Which one to consider? South East Asia J Public Heal. 2017;7(1):1–5.

Arafat SMY, Hossain MS. Suicide during international sports events (football World Cup-2018). Asian J Psychiatr. 2018;36:9293.

Arafat SMY, AkterH, Mali B. Psychiatric morbidities and risk factors of suicidal ideation among patients attending for psychiatric services at a tertiary teaching hospital in Bangladesh. Asian J Psychiatr. 2018a;34:44–46.

Arafat SMY, Akter H, Mali B. Quality of online news reporting of suicidal behavior in Bangladesh against World Health Organization guidelines. Asian J Psychiatr. in press

Arafat SMY, Mali B, Akter H. Demography and risk factors of suicidal behavior in Bangladesh: A retrospective online news content analysis. Asian J Psychiatr. 2018b;36:96-99.

Bachmann S. Epidemiology of suicide and the psychiatric perspective. Int. J. Environ. Res. Public Health. 2018;15:1425

Begum A, Khan NT, Shafiuzzaman A, Shahid F, Anam AA, Ahmed KS, et al. Suicidal death due to hanging. Delta Med Coll J. 2017a;5:89–93.

Begum A, Rahman AKMF, Rahman A, Soares J, Khankeh HR, Macassa G. Prevalence of suicide ideation among adolescents and young adults in rural Bangladesh. Int J Mental Health. 2017b;46:177–187.

Chowdhury FR, Dewan G, Verma VR, Knipe DW, Isha IT, Faiz MA, et al. Bans of WHO class I pesticides in Bangladesh—suicide prevention without hampering agricultural output. Int J Epidemiol. 2018;47:175–184.

Debnath CR, Debnath MR, Alam MM, Moshwan MM. A case of acute insulin poisoning with attempt to suicide. Mymensingh Med J. 2014;23(4):800-802.

Feroz AHM, Islam SMN, Reza S, Rahman AKMM, Sen J, Mowla M, et al. A community survey on the prevalence of suicidal attempts and deaths in a selected rural area of Bangladesh. J Medicine. 2012;13:3-9.

Ghanbari B, Malakouti SK, Nojomi M, Alavi K, Khaleghparast S. Suicide prevention and follow-up services: a narrative review. Glob J Health Sci. 2016;8:145-153.

Halim KS, Khondker L, Wahab MA, Nargis F, Khan SI. Various factors of attempted suicide in a selected area of Naogaon district. Mymensingh Med J. 2010;19(2):244-249.

Higgins JPT, Altman DG. Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions version 5.1. The Cochrane Collaboration; 2017.Available: http://www.cochranehandbook.org/. Accessed 02 October 2018.

Jordans MJD, Kaufman A, Brenman NF, Adhikari RP, Luitel NP, Tol WA, et al. Suicide in south Asia: a scoping review. BMC Psychiatry. 2014;14:358.

Khan MM. Suicide prevention and developing countries. J R Soc Med. 2005;98:459–563.

Khan MM. Suicide on the Indian Subcontinent. Crisis. 2002;23:104– 107.

Knipe DW, Carroll R, Thomas KH, Pease A, Gunnell D, Metcalfe C. Association of socio-economic position and suicide/attempted suicide in low and middle income countries in South and South-East Asia - a systematic review. BMC Public Health. 2015;15:1055.

Mashreky SR, Rahman F, Rahman A. Suicide kills more than 10,000 people every year in Bangladesh. Arch Suicide Res. 2013;17:387–396.

Malakouti SK, Nojomi M, Poshtmashadi M, Shooshtari MH, Moghadam FM, Rahimi-Movaghar A, et al. Integrating a suicide prevention program into the primary health care network: A field trial study in Iran. Biomed Res Int. 2015;2015:9.

Mann J, Haas A, Mehlum L, Phillips M. Suicide Prevention Strategies. JAMA. 2005;294:2064-2074.

Quader M, Rahman MH, Kamal M, Ahmed AU, Saha SK. Post mortem outcome of organophosphorus compound poisoning cases at Mymensingh Medical College. Mymensingh Med J. 2010;19(2):170-172.

Qusar MS, Morshed NM, Azad AMK, Kader MA, Shams SF, Ahmed FM, et al. Psychiatric morbidity among suicide attempters who needed ICU intervention. Bangabandhu Sheikh Mujib Med University J. 2009;2:73–77.

Reza AS, Feroz AHM, Islam SN, Karim MN, Rabbani MG, Alam MS, et al. Risk factors of suicide and para suicide in rural Bangladesh. J Medicine.2014;14:123-129.

Ruzicka LT. Suicide in countries and areas of the ESCAP region. Asia-Pacific Population Journal.1998;13:55–74.

Shah MMA, Sajib MWH, Arafat SMY. Demography and risk factor of suicidal behavior in Bangladesh: A cross-sectional observation from patients attending a suicide prevention clinic of Bangladesh. Asian J Psychiatr. 2018;35:4–5.

Shah MMA, Ahmed S, Arafat SMY. Demography and risk factors of suicide in Bangladesh: A six-month paper content analysis. Psychiatry J.2017;2017:3047025.

Shahnaz A, Bagley C, Simkhada P, Kadri S. Suicidal behaviour in Bangladesh: A scoping literature review and a proposed public health prevention model. Open J Soc Sciences. 2017;5:254–282.

Salam SS, Alonge O, Islam M, Hoque D, Wadhwaniya S, UlBaset M, et al. The burden of suicide in rural Bangladesh: magnitude and risk factors. Int J Environ Res Public Health. 2017;14:1032.

Suryadevara U, Tandon R. Decriminalization of attempted suicide across Asia- it matters!. Asian J. Psychiatr. 2018;35:A2–A3.

Tandon R, Nathani MK. Increasing suicide rates across Asia- a public health crisis. Asian J Psychiatr. 2018;36:A2–A4.

World Health Organization. Preventing suicide: A global imperative. Geneva. 2014.http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/ [Accessed on 01 July 2018]

Wu KC, Chen YY, Yip PS. Suicide methods in Asia: implications in suicide prevention. Int J Environ Res Public Health. 2012;9(4):1135-1158.

Zalsman G, Hawton K, Wasserman D, van Heeringen K, Arensman E, Sarchiapone M, et al. Suicide prevention strategies revisited: 10year systematic review. Lancet Psychiatry.2016;3:646-659.

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