Advertisement

Social Psychiatry and Psychiatric Epidemiology

, Volume 52, Issue 12, pp 1483–1494 | Cite as

Suicide in Nepal: a modified psychological autopsy investigation from randomly selected police cases between 2013 and 2015

  • Ashley K. HagamanEmail author
  • S. Khadka
  • S. Lohani
  • B. Kohrt
Original Paper

Abstract

Purpose

Yearly, 600,000 people complete suicide in low- and middle-income countries, accounting for 75% of the world’s burden of suicide mortality. The highest regional rates are in South and East Asia. Nepal has one of the highest suicide rates in the world; however, few investigations exploring patterns surrounding both male and female suicides exist. This study used psychological autopsies to identify common factors, precipitating events, and warning signs in a diverse sample.

Methods

Randomly sampled from 302 police case reports over 24 months, psychological autopsies were conducted for 39 completed suicide cases in one urban and one rural region of Nepal.

Results

In the total police sample (n = 302), 57.0% of deaths were male. Over 40% of deaths were 25 years or younger, including 65% of rural and 50.8% of female suicide deaths. We estimate the crude urban and rural suicide rates to be 16.1 and 22.8 per 100,000, respectively. Within our psychological autopsy sample, 38.5% met criteria for depression and only 23.1% informants believed that the deceased had thoughts of self-harm or suicide before death. Important warning signs include recent geographic migration, alcohol abuse, and family history of suicide.

Conclusions

Suicide prevention strategies in Nepal should account for the lack of awareness about suicide risk among family members and early age of suicide completion, especially in rural and female populations. Given the low rates of ideation disclosure to friends and family, educating the general public about other signs of suicide may help prevention efforts in Nepal.

Keywords

Suicide Low-income Psychological autopsy Depression Nepal 

Notes

Acknowledgements

The authors are deeply grateful for the valuable support and mentorship of Transcultural Psychosocial Organization (TPO) Nepal, particularly Mr. Nandaraj Acharya, Mr. Safar Bikram Adhikari, Mr. Nagendra Luitel, and Mr. Suraj Koirala. We are also gracious for the assistance of Jumla District and Kathmandu District police officers as well as Action Works Nepal staff and community leaders.

Compliance with ethical standards

Financial support

AH was supported by US Fulbright Student Research Program and the National Science Foundation Cultural Anthropology Doctoral Dissertation Research Improvement Grant (Award 1459811). BAK was supported by the U.S. National Institute of Mental Health (K01MH104310).

Conflict of interest

The authors declare that there is no conflict of interest.

Ethical standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Availability of data and materials

Quantitative data resulting from the psychological autopsies and qualitative coding queries and code book information may be requested from the first author. Institutional suicide surveillance and reporting data are not available from the authors. For this information, researchers are encouraged to directly contact law enforcement and health institutions in Nepal.

References

  1. 1.
    World Health Organization (2014) Preventing suicide: a global imperative. World Health Organization, Geneva, SwitzerlandGoogle Scholar
  2. 2.
    Bertolote JM, Fleischmann A, Butchart A, Besbelli N (2006) Suicide, suicide attempts and pesticides: a major hidden public health problem. Bull World Health Org 84:260CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Phillips MR (2010) Rethinking the role of mental illness in suicide. Am J Psychiatry 167:731–733CrossRefPubMedGoogle Scholar
  4. 4.
    Iemmi V, Bantjes J, Coast E, Channer K, Leone T, McDaid D et al (2016) Suicide and poverty in low-income and middle-income countries: a systematic review. Lancet Psychiatry 3(8):774–783CrossRefPubMedGoogle Scholar
  5. 5.
    Knipe DW, Carroll R, Thomas KH, Pease A, Gunnell D, Metcalfe C (2015) 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 15:1055CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Hendin H, Phillips MR, Vijayakumar L, Pirkis J, Wang H, Yip P, Wasserman D, Bertolote JM, Fleischmann A (2008) Suicide and suicide prevention in Asia. Mental Health and Substance Abuse, World Health Organization, Geneva, SwitzerlandGoogle Scholar
  7. 7.
    Vijayakumar L, Pirkis J, Huong TT, Yip P, Seneviratne RDA, Hendin H (2008) Socio-economic, cultural and religious factors affecting suicide prevention in Asia. Suicide and Suicide Prevention in Asia. World Health Organization, Geneva, pp 19–30Google Scholar
  8. 8.
    Vijayakumar L, John S, Pirkis J, Whiteford H (2005) Suicide in developing countries (2): risk factors. Crisis 26(3):112–119CrossRefPubMedGoogle Scholar
  9. 9.
    Bertolote JM, Fleischmann A, De Leo D, Bolhari J, Botega N, De Silva D et al (2005) Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey. Psychol Med 35(10):1457–1465CrossRefPubMedGoogle Scholar
  10. 10.
    Kral MJ, Links PS, Bergmans Y (2012) Suicide studies and the need for mixed methods research. J Mixed Methods Res 6(3):236–249CrossRefGoogle Scholar
  11. 11.
    Hjelmeland H, Knizek BL (2010) Why we need qualitative research in suicidology. Suicide Life Threat Behav 40(1):74–80CrossRefPubMedGoogle Scholar
  12. 12.
    Hagaman AK, Maharjan U, Kohrt BA (2016) Suicide surveillance and health systems in Nepal: a qualitative and social network analysis. Int J Mental Health Syst 10:46CrossRefGoogle Scholar
  13. 13.
    Institute for Health Metrics and Evaluation. GBD Compare Data Visualization. Retrieved from http://vizhub.healthdata.org/gbd-compare. Accessed 21 Dec 2016
  14. 14.
    Suvedi BK, Pradhan A, Barnett S, Puri M, Chitrakar SR, Poudel P et al (2009) Nepal maternal mortality and morbidity study 2008/2009: summary of preliminary findings. Kathmandu, Nepal: Family Health Division, Department of Health Services, Ministry of Health, Government of NepalGoogle Scholar
  15. 15.
    Pradhan A, Poudel P, Thomas D, Barnett S (2011) A review of the evidence: suicide among women in Nepal. Kathmandu: National Health Sector Support Program, Ministry of Health and PopulationGoogle Scholar
  16. 16.
    Borges G, Nock MK, Abad JMH, Hwang I, Sampson NA, Alonso J et al (2010) Twelve month prevalence of and risk factors for suicide attempts in the WHO World Mental Health Surveys. J Clin Psychiatry 71(12):1617CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Nock MK, Hwang I, Sampson N, Kessler RC, Angermeyer M, Beautrais A et al (2009) Cross-national analysis of the associations among mental disorders and suicidal behavior: findings from the WHO World Mental Health Surveys. PLoS Med 6(8):e1000123CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Fleischmann A, Bertolote JM, De Leo D, Botega N, Phillips M, Sisask M et al (2005) Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middle-income countries. Psychol Med 35(10):1467–1474CrossRefPubMedGoogle Scholar
  19. 19.
    Kizza D, Hjelmeland H, Kinyanda E, Knizek BL (2012) Alcohol and suicide in postconflict Northern Uganda: A qualitative psychological autopsy study. Crisis 33(2):95–105CrossRefPubMedGoogle Scholar
  20. 20.
    Hjelmeland H, Knizek BL (2016) Qualitative evidence in suicide: findings from qualitative psychological autopsy studies. In: Handbook of qualitative health research for evidence-based practice. Springer, New York, NY, pp 355–371CrossRefGoogle Scholar
  21. 21.
    Shneidman ES (1994) The psychological autopsy. Am Psychol 49(1):75–76CrossRefGoogle Scholar
  22. 22.
    Appleby L, Cooper J, Amos T, Faragher B (1999) Psychological autopsy study of suicides by people aged under 35. Br J Psychiatry 175(2):168–174CrossRefPubMedGoogle Scholar
  23. 23.
    Phillips MR, Yang G, Zhang Y, Wang L, Ji H, Zhou M (2002) Risk factors for suicide in China: a national case-control psychological autopsy study. Lancet 360(9347):1728–1736CrossRefPubMedGoogle Scholar
  24. 24.
    Hagaman AK, Sivilli TI, Ao T, Blanton C, Ellis H, Cardozo BL et al (2016) An investigation into suicides among bhutanese refugees resettled in the United States between 2008 and 2011. J Immigr Minor Health 18(4):819–827CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Kohrt BA, Luitel NP, Acharya P, Jordans MJ (2016) Detection of depression in low resource settings: validation of the Patient Health Questionnaire (PHQ-9) and cultural concepts of distress in Nepal. BMC Psychiatry 16(1):58CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    CDC (2005) Web-based injury statistics query and reporting system (WISQARS) [online]. In: Control. NCfIPa, editorGoogle Scholar
  27. 27.
    Gunnell D, Eddleston M, Phillips MR, Konradsen F (2007) The global distribution of fatal pesticide self-poisoning: systematic review. BMC Public Health 7:357CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Nepal Central Bureau of Statistics (2012) National population and housing census 2011. Kathmandu, Nepal: Government of Nepal, National Planning Commission Secretariat, Central Bureau of StatisticsGoogle Scholar
  29. 29.
    Cameron MM (1998) On the edge of the auspicious: gender and caste in Nepal. University of Illinois Press, IllinoisGoogle Scholar
  30. 30.
    Halliburton M (1998) Suicide: a paradox of development in Kerala. Economic and political weekly, pp 2341–2345Google Scholar
  31. 31.
    Chua JL (2014) In pursuit of the good life: aspiration and suicide in globalizing south India. University of California Press, CaliforniaCrossRefGoogle Scholar
  32. 32.
    Wagenaar B, Hagaman A, Kaiser B, McLean K, Kohrt B (2012) Depression, suicidal ideation, and associated factors: a cross-sectional study in rural Haiti. BMC Psychiatry 12(1):149CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Eggerman M, Panter-Brick C (2010) Suffering, hope, and entrapment: resilience and cultural values in Afghanistan. Soc Sci Med 71(1):71–83CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Munster DN (2015) Farmers’ suicides as public death: politics, agency and statistics in a suicide-prone district (South India). Mod Asian Stud 49(5):1580–1605CrossRefGoogle Scholar
  35. 35.
    Bhise MC, Behere PB (2016) Risk factors for farmers’ suicides in central rural India: matched case–control psychological autopsy study. Indian J Psychol Med 38(6):560CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Meltzer H, Bebbington P, Brugha T, Jenkins R, McManus S, Dennis M (2011) Personal debt and suicidal ideation. Psychol Med 41(04):771–778CrossRefPubMedGoogle Scholar
  37. 37.
    Chavez-Hernandez AM, Macias-Garcia LF (2016) Understanding suicide in socially vulnerable contexts: psychological autopsy in a small town in Mexico. Suicide Life Threat Behav 46(1):3–12CrossRefPubMedGoogle Scholar
  38. 38.
    Vijayakumar L (2016) Suicide prevention: beyond mental disorder. Indian J Psychol Med 38(6):514CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Qin P, Agerbo E, Mortensen PB (2003) Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register—based study of all suicides in Denmark, 1981–1997. Am J Psychiatry 160(4):765–772CrossRefPubMedGoogle Scholar
  40. 40.
    Paudel GS (2007) Domestic violence against women in Nepal. Gender Technol Dev 11(2):199–233CrossRefGoogle Scholar
  41. 41.
    Bradley F, Smith M, Long J, O’dowd T (2002) Reported frequency of domestic violence: cross sectional survey of women attending general practice. BMJ 324(7332):271CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Tuladhar S, Khanal KR, Lila K, Ghimire PK, Onta K (2013) Womens empowerment and spousal violence in relation to health outcomes in Nepal: further analysis of the 2011 Nepal Demographic and Health SurveyGoogle Scholar
  43. 43.
    Pun KD, Infanti JJ, Koju R, Schei B, Darj E, Group AS (2016) Community perceptions on domestic violence against pregnant women in Nepal: a qualitative study. Global Health Act 9(1):31964CrossRefGoogle Scholar
  44. 44.
    Kohrt BA, Bourey C (2016) Culture and comorbidity: intimate partner violence as a common risk factor for maternal mental illness and reproductive health problems among former child soldiers in Nepal. Med Anthropol Q 30(4):515–535CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Devries K, Watts C, Yoshihama M, Kiss L, Schraiber LB, Deyessa N et al (2011) Violence against women is strongly associated with suicide attempts: evidence from the WHO multi-country study on women’s health and domestic violence against women. Soc Sci Med 73(1):79–86CrossRefPubMedGoogle Scholar
  46. 46.
    Mohanty S, Sahu G, Mohanty MK, Patnaik M (2007) Suicide in India—a four year retrospective study. J Forensic Leg Med 14(4):185–189CrossRefPubMedGoogle Scholar
  47. 47.
    Patel V, Ramasundarahettige C, Vijayakumar L, Thakur JS, Gajalakshmi V, Gururaj G et al (2012) Suicide mortality in India: a nationally representative survey. Lancet 379(9834):2343–2351CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Kolves K, Värnik A, Tooding L-M, Wasserman D (2006) The role of alcohol in suicide: a case-control psychological autopsy study. Psychol Med 36(07):923–930CrossRefPubMedGoogle Scholar
  49. 49.
    Vijayakumar L, Kumar MS, Vijayakumar V (2011) Substance use and suicide. Curr Opin Psychiatry 24(3):197–202CrossRefPubMedGoogle Scholar
  50. 50.
    Pompili M, Murri MB, Patti S, Innamorati M, Lester D, Girardi P et al (2016) The communication of suicidal intentions: a meta-analysis. Psychol Med 46(11):2239–2253CrossRefPubMedGoogle Scholar
  51. 51.
    Chavan B, Singh GP, Kaur J, Kochar R (2008) Psychological autopsy of 101 suicide cases from northwest region of India. Indian J Psychiatry 50(1):34CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Conner KR, Duberstein PR, Conwell Y, Caine ED (2003) Reactive aggression and suicide: theory and evidence. Aggress Violent Beh 8(4):413–432CrossRefGoogle Scholar
  53. 53.
    Chachamovich E, Ding Y, Turecki G (2012) Levels of aggressiveness are higher among alcohol-related suicides: results from a psychological autopsy study. Alcohol 46(6):529–536CrossRefPubMedGoogle Scholar
  54. 54.
    Rajappa K, Gallagher M, Miranda R (2012) Emotion dysregulation and vulnerability to suicidal ideation and attempts. Cognit Ther Res 36(6):833–839CrossRefGoogle Scholar
  55. 55.
    Yang GH, Phillips MR, Zhou MG, Wang LJ, Zhang YP, Xu D (2005) Understanding the unique characteristics of suicide in China: national psychological autopsy study. Biomed Environ Sci 18(6):379–389PubMedGoogle Scholar
  56. 56.
    Ji J, Kleinman A, Becker AE (2001) Suicide in contemporary China: a review of China’s distinctive suicide demographics in their sociocultural context. Harv Rev Psychiatry 9(1):1–12CrossRefPubMedGoogle Scholar
  57. 57.
    Thornicroft G, Chatterji S, Evans-Lacko S, Gruber M, Sampson N, Aguilar-Gaxiola S et al (2017) Undertreatment of people with major depressive disorder in 21 countries. Br J Psychiatry 210(2):119–124CrossRefPubMedGoogle Scholar
  58. 58.
    Shidhaye R, Murhar V, Gangale S, Aldridge L, Shastri R, Parikh R et al (2017) The effect of VISHRAM, a grass-roots community-based mental health programme, on the treatment gap for depression in rural communities in India: a population-based study. Lancet Psychiatry 4(2):128–135CrossRefPubMedGoogle Scholar
  59. 59.
    Kohrt BA, Speckman RA, Kunz RD, Baldwin JL, Upadhaya N, Acharya NR et al (2009) Culture in psychiatric epidemiology: using ethnography and multiple mediator models to assess the relationship of caste with depression and anxiety in Nepal. Ann Hum Biol 36(3):261–280CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Kohrt BA, Worthman CM (2009) Gender and anxiety in Nepal: the role of social support, stressful life events, and structural violence. CNS Neurosci Ther 15(3):237–248CrossRefPubMedGoogle Scholar
  61. 61.
    Milner A, Hjelmeland H, Arensman E, De Leo D (2013) Social-environmental factors and suicide mortality: a narrative review of over 200 articles. Sociol Mind 3(2):137CrossRefGoogle Scholar
  62. 62.
    Fleischmann A, Arensman E, Berman A, Carli V, De Leo D, Hadlaczky G et al. (2016) Overview evidence on interventions for population suicide with an eye to identifying best-supported strategies for LMICs. Glob Ment Health 3:e5CrossRefGoogle Scholar
  63. 63.
    Zalsman G, Hawton K, Wasserman D, van Heeringen K, Arensman E, Sarchiapone M et al (2016) Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry 3(7):646–659CrossRefPubMedGoogle Scholar
  64. 64.
    Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A et al (2005) Suicide prevention strategies—a systematic review. JAMA J Am Med Assoc 294(16):2064–2074CrossRefGoogle Scholar
  65. 65.
    Kohrt BA, Blasingame E, Compton MT, Dakana SF, Dossen B, Lang F et al (2015) Adapting the crisis intervention team (CIT) Model of police–mental health collaboration in a low-income, post-conflict country: curriculum development in liberia, West Africa. Am J Public Health 105(3):e73–e80CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Lund C, Tomlinson M, Patel V (2016) Integration of mental health into primary care in low-and middle-income countries: the PRIME mental healthcare plans. Br J Psychiatry 208(Suppl 56):s1–s3CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Vijayakumar L, Jeyaseelan L, Kumar S, Mohanraj R, Devika S, Manikandan S (2013) A central storage facility to reduce pesticide suicides—a feasibility study from India. BMC Public Health 13(1):850CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Gunnell D, Fernando R, Hewagama M, Priyangika W, Konradsen F, Eddleston M (2007) The impact of pesticide regulations on suicide in Sri Lanka. Int J Epidemiol 36(6):1235–1242CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Jordans MRS, Fekadu A, Medhin G, Kigozi F, Kohrt BA, Luitel N, Petersen I, Shidhaye R, Ssebunnya J, Patel V, Lund C (2017) Suicidal ideation and behaviour among community and health care seeking populations in five low and middle-income countries: a cross-sectional study. Epidemiol Psychiatri Sci. doi: 10.1017/S2045796017000038 Google Scholar
  70. 70.
    Pouliot L, De Leo D (2006) Critical issues in psychological autopsy studies. Suicide Life Threat Behav 36(5):491–510CrossRefPubMedGoogle Scholar
  71. 71.
    Phillips DP, Ruth TE (1993) Adequacy of official suicide statistics for scientific-research and public-policy. Suicide Life Threat Behav 23(4):307–319PubMedGoogle Scholar
  72. 72.
    Rockett I, Kapusta ND, Bhandari R (2011) Suicide misclassification in an international context: revisitation and update. Suicidol Online 2:48–61Google Scholar
  73. 73.
    Conner KR, Beautrais AL, Brent DA, Conwell Y, Phillips MR, Schneider B (2012) The next generation of psychological autopsy studies. Suicide Life Threat Behav 42(1):86–103CrossRefPubMedGoogle Scholar
  74. 74.
    Cavanagh JT, Carson AJ, Sharpe M, Lawrie S (2003) Psychological autopsy studies of suicide: a systematic review. Psychol Med 33(3):395–405CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Research DepartmentTranscultural Psychosocial Organization NepalKathmanduNepal
  3. 3.Nobel CollegePokhara UniversityKathmanduNepal
  4. 4.Department of PsychiatryGeorge Washington UniversityWashingtonUSA

Personalised recommendations