Suicide by poisoning in Pakistan: review of regional trends, toxicity and management of commonly used agents in the past three decades.

Maria Safdar,Pervaiz Zarif,Zahid Farooq Baig,Zoe Smith,Filza Ali,Khalid Imran Afzal

doi:10.1192/bjo.2021.923

Abstract

Suicide is one of the leading mental health crises and takes one life every 40 seconds. Four out of every five suicides occur in low- and middle-income countries. Despite religion being a protective factor against suicide, the estimated number of suicides is rapidly increasing in Pakistan. Our review focuses on the trends of suicide and means of self-poisoning in the past three decades, and the management of commonly used poisons. We searched two electronic databases (PubMed and PakMediNet) for published English-language studies describing agents used for suicide in different regions of Pakistan. A total of 46 out of 85 papers (N = 54 747 cases) met our inclusion criteria. Suicidal behaviour was more common among individuals younger than 30 years. Females comprised 60% of those who attempted suicide in our study sample, although the ratio of completed suicides favoured males. There were regional trends in the choice of agent for overdose. Organophosphate poisoning was reported across the nation, with a predominance of cases from the agricultural belt of South Punjab and interior Sindh. Aluminium phosphide ('wheat pills') was a preferred agent in North Punjab, whereas paraphenylenediamine ('kala pathar') was implicated in deaths by suicide from South Punjab. Urban areas had other means for suicide, including household chemicals, benzodiazepines, kerosene oil and rat poison. Urgent steps are needed, including psychoeducational campaigns on mental health and suicide, staff training, medical resources for prompt treatment of self-poisoning and updated governmental policy to regulate pesticide sales.

Highlights

Suicide is one of the leading mental health crises and takes one life every 40 seconds
Our study found that there are striking regional and urban versus rural differences in the choice of agents used for suicide
We should launch customised mental health literacy and public health awareness campaigns across the country, to address the stigma against suicide and mental health

Summary

Methods

We searched two electronic databases (PubMed and PakMediNet) for published English-language studies describing agents used for suicide in different regions of Pakistan. We searched two electronic databases (PubMed and PakMediNet) for studies describing agents used for suicide in different regions. We considered studies published in the English language within the past 30 years, and conducted the search from October to December 2019. Case series and case reports, focusing on different agents used by adults of both genders, aged ≥18 years, who attempted suicide. Studies involving ex-pat Pakistanis and those using means of suicide other than overdose were excluded. We did not include single case reports as most focused on uncommon means of death or unusual clinical presentations that were not the focus of our study.

Results

Discussion

Conclusion