DefinePK

Abstract

Suicide and parasuicide have been identified as serious public health problems in many countries of the world1. Hospital admissions following parasuicide are a considerable drain on resources in both primary and secondary health care1. For many years it had been believed by laymen as well as scientists that suicidal behaviour was the ‘byproduct and dubious prerogative’ of Western industrialized societies while other parts of the world and particularly more ‘primitive’ societies were free of it2. Research over the past eighty years has shown conclusively that suicidal behaviour occurs in almost all cultures and societies, under a variety of circumstances and across different phases of the life cycle2.
In the 1989 World Health Statistics Annual3 only 39 of the 166 Member States of the United Nations are listed as reporting data on mortality by suicide. Altogether these 39 countries report 208,349 suicidal deaths in one year. If all member states were to report suicide mortality, there is no doubt this figure would more than double. Pakistan is not one of the countries that reports on mortality by suicides to the WHO4. Suicide does occur in all of the non-reporting countries and there is more than suggestive evidence that in some of these countries the suicide rate at times equals or even surpasses the highest rates reported officially4. This is probably true for Pakistan where there is great discrepancy between rates based on official police records and the actual extent of the problem5.
Similarly, in several countries pamsuicide today comprises one of the most frequent reasons for emergency hospital admissions in young people. The majority of parasuicides are by people below 35 years of age and they constitute a pooi from which many of the future suicides are drawn.
While there has been plethora of research on suicidal behaviour from Westerneountrics (and some Asiancountries) there has been a conspicuous absence of research on suicidal behaviour from Pakistan, There appears to be a widely held belief that due to religious reasons suicide does not occur in Muslim countries and even if it did the incidence is very small. This thinking appears to have disssuaded researchers from conducting any scientific study of the subject in Pakistan. This is reflected by the fact that to date there have been only five studies on the subject from Pakistan6-10. Two other studies, while not directly addressing the issue of suicide or parasuicide, reported on hospital admissions for acute poisoning in Karachi11-12.
What is the reason for this and why is suicidal behaviour such a poorly studied subject in Pakistan? To answer these questions it may be pertinent to look at the subject of suicidal behaviour in the context of religio-socio-culturnl and legal nouns as they exist in Pakistan. Islam forbids the taking of one’s life. The law in Pakistan (based on this tenet of Islam) considers suicide and parasuicide as criminal offenses (PPC 309 of the Criminal Procedure Act) punishable with ajail term and/or a fine of upto Rs. 10,000.00. By law all cases of parasuicide should be reported to the police of the area where the person is resident. To avoid complications inherent in a police case people seek medical treatment in various private hospitals and clinics. These hospitals neither record these cases as parasuicide nor report them to the police. It is not unknown for the police to harass parasuicide victims and their families and extort money from them.
Similarly due to religious reasons, suicide in a family is considered a shameful act and one that must be concealed. Families in which suicide has taken place are often ostracized, shunned and viewed with suspicion. There may be long term implications for the families for example on the marriage prospects of girls in the family. There is also a great deal of stigma attached to seeking help for psychological distress in Pakistaa People avoid going to psychiatrists for fear of being labelled as a mental case. Even after a hospital admission and psychiatric consultation following an overdose the follow-up rate remains low8. Studies of hospital admissions for parasuicide in Pakistan5,8,12 show most people to be young, under the age of 30 years with more females than males. However, an important difference when compared to international data is of large numbers of married females. It appears that marriage instead of protecting against psychiatric morbidity is a significant source of stress for females in Pakistan; many women committing the act in the context of disturbed relationship with their husbands or in-laws10.
As regards the methods used in parasuicide in Pakistan, ‘over the counter’ availability of psychotropics especially benzodiazepines contribute to their high incidence in medicine self-poisoning cases9. When taken alone, benzodiazepines are relatively safe in overdose compared to drugs like paracetamol and salicylates. However, organophosphate insecticides are also used frequently in parsusicide in Pakistan7,9,11.12. These are extremely dangerous because of their anticholinesterase action. They are present in most households in Pakistan and their easy accessibility probably contributes to their high incidence in parasuicide cases.
An indirect measure of the scale of the problem comes from National Morbidity & Mortality Statistics which shows 36,231 cases of ‘disease, injury or death’ from ‘poisimng and toxic effects’ treated at various government hospitals and dispensaries in 1989 in Pakistan13. Although the cause of the poisoning was not specified whether accidental, homicidal or suicidal, a similar review of 1900 cases of acute poisoning in Karachi12 showed 1330 (70%) to be’suicidal orparasuicidal’. Extrapolating from this, a conservative estimate would be of more than 25,000 cases of self-poisoning that present to various government hospitals in Pakistan. If data from all private hospitals and clinics were to be added, this figure would undoubtedly be much higher.
There is an urgent need for more and better infonnation concerning the causes of suicidal behaviour, risk factors involved and methods of preventing suicidal behaviour in Pakistan, As a first step data needs to be collected from different parts of the country. Most cities have medicolegal centers where suspected suicide cases are taken. Their records need to be analyzed for trends and patterns of suicide and parasuicide. Data collection at national level should be developed in such a way that the information can be used for analytical-epiderniological studies of the characteristics of high-risk groups and the changes in those characteristics which take place overtime.
Differences between the urban and mral centers (where self- poisoning by agrochemicals may be more prevalent) should be studied. If chemicals are involved their analysis must be carried out.
There is also an urgent need to review and possibly repeal the law regarding suicide and parasuicide, so that people who commit parasuicide, especially those at risk of further suicide attempts, can seek help without fear of being persecuted by the police. This will encourage all hospitals to give timely medical treatment as well as offering psychological counselling to distressed individuals.
Lastly, the establishment of Suicide Prevention Centers in Pakistan should be given consideration. While such centers have existed for years in many Western countries, more recently they have also beenestablished in some neighbouring countries like India and Sri Lanka with encouraging results14,15. Such centers have been shown to serve the important function of offering help to many potential suicides as well as coordinating otheraspects of sucicide prevention15.