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Psychological Autopsy Study of Suicide in Karachi
- Imran Mushtaq, Salman A Mushtaq (27 November 2008)
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Reply to letter by Drs. Mushtaq & Mushtaq
- Murad M Khan (24 January 2009)
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Imran Mushtaq, Associate Specialist-Child & Adolescent Psychiatrist Milton Keynes SP-CAHMS, Eaglestone Centre, Milton Keynes, Salman A Mushtaq
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imranmushtaq{at}doctors.org.uk Imran Mushtaq, et al.
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We must congratulate Khan et al (1) for carrying out this study, a topic that, to our knowledge has not been formally studied in Pakistan. The findings are very significant Firstly, 96% of suicides victims had a diagnosable psychiatric condition with very high prevalence of depression. We know that depressive illnesses are steadily rising and WHO in 2001, has warned that by the year 2020, depressive disorders are expected to rank as the second leading cause of disease and disability worldwide after coronary heart disease (2). Interestingly none of the victims in the previous month had been in contact with any health professional, contrary to the pattern seen in the West. Secondly, violent methods were used in majority of the cases depicting the seriousness of the intent, a finding that has been replicated in number of studies from Asia. However interestingly the same finding was reported earlier by Patel and Gaw (3) in their review of Studies of suicide among immigrants from the Indian subcontinent (India, Pakistan, Bangladesh, and Sri Lanka) who used violent methods such as hanging, burning, and poisoning. None of the suicide victim used overdose of medication, which is the most common method of attempted suicide/deliberate self harm in the West. However it should be noted that violent methods are becoming increasingly common in the West with hanging as one of the common cause of completed suicides (4,5). Thirdly, risk factors for suicide do not differ greatly from the rest of the world, as reported by earlier Taiwanese (6) and Indian (7) studies, apart from alcoholism. However one striking finding reported in this study is that 62% of suicide victims lived in joint/extended families, which is supposed to be protective factor? It will be useful if the authors could clarify a couple of points as results show 24% of suicide victims were married and 51% were single but status of rest of the 25% is not mentioned (widower, divorced)? As these would be considered as major life events and whether the life event was just before the suicide. Also there does not seem to be any mention of age groups among the suicide victims? It will be an important finding to know the age group who is at greatest risk and especially if the trend differs from the west? It will be interesting to see if the findings of useful studies like this will motivate the health commissioners in Pakistan to pay attention to the mental health needs of the people. References: 1. Khan MM, Mahmud S, Karim SK, Zaman M, and Prince M. Case–control study of suicide in Karachi, Pakistan. Br J Psychiatry 2008 193: 402-405 2. World Health Organization (2001) Speech. www.int/director- general/speechs/2001/english/20011025_copingwithstressbrusseles.en.htlm 3. Patel SP, Gaw AC. Suicide among immigrants from the Indian subcontinent: a review. Psychiatry Serv 1996; 47: 517 -21. 4. Office for National Statistics. Mortality, 1996. Cause. London: Stationery Office , 1998. 5. Mittendorfer-Rutz E, Wasserman D, Rasmussen F. Fetal and childhood growth and the risk of violent and non-violent suicide attempts: a cohort study of 318,953 men.J Epidemiol Community Health. 2008 Feb; 62(2):168-73 6. Cheng AT. Mental illness and suicide. A case-control study in east Taiwan. Arch Gen Psychiatry. 1995 Jul; 52(7): 594-603. 7. Vijayakumar L, Rajkumar S. Are risk factors for suicide universal? A case-control study in India. Acta Psychiatr Scand. 1999 Jun; 99(6): 407 Authors: Imran Mushtaq, MRCPCH, MRCPsych, Associate Specialist-Child & Adolescent Psychiatrist, Milton Keynes SP-CAHMS, Eaglestone Centre, Milton Keynes Salman A Mushtaq, MRCPsych. CRHT, Coventry and Warwickshire Partnership Trust |
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Murad M Khan, Professor of Psyhciatry Aga Khan University
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murad.khan{at}aku.edu Murad M Khan
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I thank Drs. Mushtaq & Mushtaq for their comments. Re. their queries of marital status and age groups, 25% of the victims were engaged, divorced or widowed, while the age group of the victims were: 15-20 years, 24%; 21-30 years, 41%; 31-40 years, 17%; 41-50 years, 7% and >51 years, 3%. From our and other studies it appears that in Pakistan, majority of people committing suicide are young, under the age of 30 years. This is a massive loss to society and contributes to high years-of-life-lost (YLL). On the other hand suicide is rare in the elderly in Pakistan which is in contrast to the findings in the West. This may be due to the status afforded to the elderly in the family-centered Pakistani society. The elderly continue to live with family members after retirement and rarely have to fend for themselves. I agree with the other comments made by the authors: mental illness, especially depression in under-recognised and under-treated in Pakistan; most suicide victims used violent methods such as hanging, firearms, burning and poisoning, while few used medications as a method and none of the victims were in contact with health services in the month before the suicide. While these findings have important implications for suicide prevention in Pakistan, we do not see the situation changing on the ground, as far as mental health or suicide prevention is concerned. Successive governments in Pakistan (military as well as civilian) have failed to address the basic health needs of the population, allocating less than 1% of the annual budget for health. Mental health does not have a separate budget but it is believed it is 1% of the health budget. Unfortunately what little is available is eaten up by massive corruption, mismanagement and poor governance. Until these fundamental issues are addressed the population of the country will continue to suffer from high levels of distress, many of whom will go on to kill themselves. Declaration on interest: none Murad M Khan Dept of Psychiatry Aga Khan University Karachi PAKISTAN Email: murad.khan@aku.edu |
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