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

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.

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

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

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

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).

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.

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.

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 is grossly under reported and under registered in countries such as Bangladesh (Khan 20022005; 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.

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).

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).

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).

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.