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Culture, Medicine, and Psychiatry

, Volume 42, Issue 3, pp 704–734 | Cite as

Suicide in Nepal: Qualitative Findings from a Modified Case-Series Psychological Autopsy Investigation of Suicide Deaths

  • Ashley K. Hagaman
  • Seema Khadka
  • Amber Wutich
  • Shyam Lohani
  • Brandon A. Kohrt
Original Paper

Abstract

South Asia accounts for the majority of the world’s suicide deaths, but typical psychiatric or surveillance-based research approaches are limited due to incomplete vital surveillance. Despite rich anthropological scholarship in the region, such work has not been used to address public health gaps in surveillance and nor inform prevention programs designed based on surveillance data. Our goal was to leverage useful strategies from both public health and anthropological approaches to provide rich narrative reconstructions of suicide events, told by family members or loved ones of the deceased, to further contextualize the circumstances of suicide. Specifically, we sought to untangle socio-cultural and structural patterns in suicide cases to better inform systems-level surveillance strategies and salient community-level suicide prevention opportunities. Using a mixed-methods psychological autopsy approach for cross-cultural research (MPAC) in both urban and rural Nepal, 39 suicide deaths were examined. MPAC was used to document antecedent events, characteristics of persons completing suicide, and perceived drivers of each suicide. Patterns across suicide cases include (1) lack of education (72% of cases); (2) life stressors such as poverty (54%), violence (61.1%), migrant labor (33% of men), and family disputes often resulting in isolation or shame (56.4%); (3) family histories of suicidal behavior (62%), with the majority involving an immediate family member; (4) gender differences: female suicides were attributed to hopeless situations, such as spousal abuse, with high degrees of social stigma. In contrast, male suicides were most commonly associated with drinking and resulted from internalized stigma, such as financial failure or an inability to provide for their family; (5) justifications for suicide were attributions to ‘fate’ and personality characteristics such as ‘stubbornness’ and ‘egoism’; (5) power dynamics and available agency precluded some families from disputing the death as a suicide and also had implications for the condemnation or justification of particular suicides. Importantly, only 1 out of 3 men and 1 out of 6 women had any communication to family members about suicidal ideation prior to completion. Findings illustrate the importance of MPAC methods for capturing cultural narratives evoked after completed suicides, recognizing culturally salient warning signs, and identifying potential barriers to disclosure and justice seeking by families. These findings elucidate how suicide narratives are structured by family members and reveal public health opportunities for creating or supplementing mortality surveillance, intervening in higher risk populations such as survivors of suicide, and encouraging disclosure.

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. Nanda Raj 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. We appreciate the support of the Nepal Health Research Council. AH was supported by US Fulbright Student Research Program and the National Science Foundation Cultural Anthropology Doctoral Dissertation Research Improvement Grant [Award 1459811]. We are grateful to the Carolina Population Center and NIH/NICHD for training support (T32 HD007168) and for general support (P2C HD050924). BAK receives salary support from the U.S. National Institute of Mental Health [K01MH104310].

Compliance with Ethical Standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Supplementary material

11013_2018_9585_MOESM1_ESM.docx (13 kb)
Supplementary material 1 (DOCX 13 kb)

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Authors and Affiliations

  1. 1.Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Transcultural Psychosocial Organization Nepal, Research DepartmentKathmanduNepal
  3. 3.School of Human Evolution and Social ChangeArizona State UniversityTempeUSA
  4. 4.Nobel CollegePokhara UniversityKathmanduNepal
  5. 5.Department of PsychiatryGeorge Washington UniversityWashingtonUSA

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