A retrospective five-year autopsy based study of suicide in Punjab province of Pakistan

Abstract

Background

Suicide deaths are significantly under-reported in Pakistan due, in part, to the absence of a national registry of suicide and stigma resulting from its illegal status until recently. Past studies of suicide by forensic autopsy have focused on larger cities. We aimed to identify the pattern of suicidal deaths in five rural districts in Punjab Province of Pakistan.

Methods

The data included all autopsies performed for suspected suicide in five districts of Punjab province (Bhakkar, Okara, Nankana Sahib, Khanewal and Khushab) over five years between January 2018 and December 2022, identified through collaboration with the Surgeon Medicolegal Punjab Office and district medico-legal officers. Demographic information and post-mortem toxicological findings were collected through a pre-designed proforma based on previous research.

Results

A total of 205 autopsies due to suspected suicides were identified. Most were aged under 30 years (133/205, 64.9%) and the male-to-female ratio was observed as 1.1:1. The most common methods overall were ingestion of poisonous substances (80/205, 39%; 18.5% of men and 61.9% of women) and hanging (75/205, 36.6%; 46.3% of men and 25.8% of women). Kala-pathar (paraphenylenediamine hair dye) was the most common ingested poison (41/80, 51.3%) followed by aluminium phosphide (formulated as 56% of 3 g fumigant wheat pills). Domestic conflict was the most common motive identified.

Conclusions

This retrospective review of suicide autopsy cases in five districts of the Pakistan Punjab showed that poisoning was the most common means of suicide, particularly with paraphenylenediamine hair dye. There is need for systematic collection of such data from all districts across Pakistan, which can lead to the development of a national suicide registry. This will allow official reporting of suicide deaths on a national level to help guide development and monitoring of an effective suicide prevention strategy.

Background

Suicide, defined as “a death caused by injuring oneself with the intent to die,” [1] is considered one of the leading causes of death in people aged 15–29 years worldwide [2]. According to the World Health Organization (WHO), around 703,000 people take their own life every year and, for every act of suicide, there are at least 10–20 acts of self-harm [2]. About 77% of these suicide deaths occur in low- and middle-income countries (LMIC) [2]. Suicide has a strong link to mental disorders such as depression and substance addiction, but can also be seen as an extreme response to sudden life-changing calamities like financial problems, chronic diseases, arguments, and changes in relationships. It remains one of the leading preventable causes of death worldwide [3].

Pakistan lacks a national registry for suicide cases, leading to underreported data with estimates ranging from 5 to 10 cases per 100,000 population by the WHO [4]. The criminalization of suicide up until December 2022 [5] hindered prevention efforts, as individuals feared prosecution [6]. Cultural taboos and stigmatization may contribute to underreporting [4]. Governance issues affect the accuracy of suicide data. Although medicolegal reports don’t reveal the actual numbers, they provide insight into the issue [7].

The limited studies done, despite religious and cultural barriers, emphasize the importance of acknowledging suicide as a significant cause of death in Pakistan [7]. Similar to many other lower middle income countries [8], the commonly used methods for suicides in Pakistan are reported to be hanging and poison ingestion, followed closely by firearms and drowning [9]. Wheat pills and kala-pathar (paraphenylenediamine hair dye) are two of the most common poisons ingested in Punjab Province, Pakistan [10]. Suicide motives in Pakistan are often hidden due to shame and societal taboos; with domestic issues, financial difficulties, unemployment, parental opposition, and mental illness as primary catalysts [11].

It is important to understand the context of autopsies done in suicide cases. During the timeframe when it was criminalized, and even now following decriminalization, suicide is treated like homicide as a suspicious death. When an individual dies, or an unwell patient dies after s/he arrives at a hospital, the attending doctor must promptly inform the police if suspecting foul play or unnatural causes like homicide or suicide. In district headquarters hospitals, where at least one police officer is typically on duty or is summoned as needed, an inquiry is initiated leading to a First Information Report (FIR). The FIR marks the start of legal proceedings, granting the police authority to request an autopsy based on information from relatives and crime scene investigations. In Pakistan, the entire process is police-driven, with autopsies performed by the Medicolegal Officer (MLO) if deemed necessary. The process of recording suspected suicides is highly variable, influenced by factors such as sociocultural values. Forensic autopsies may not occur due to cultural norms and family pressure on the police to avoid labeling it as suicide. Delays in autopsy, along with these cultural factors, contribute to inaccurate reporting of suicide cases.

Punjab is the province with largest population in Pakistan. It had 36 districts and population of 110 million at the time of census of 2017 [12]. It has been redistributed to 42 districts with a population of about 127.5 million in census of 2023 [12]. Previous studies of suicide have mostly focused on the bigger districts of Punjab, such as Lahore and Faisalabad, and data from the smaller districts hasn’t been included according to our knowledge [7]. This study aims to fill a gap in the existing knowledge by utilizing data from all suicide records provided by district medico-legal officers from across five diverse districts of Punjab Province. This study aims to provide a more general description of suicidal cases in rural Pakistan by encompassing a wide range of socioeconomic backgrounds and geographical locations. Given the scarcity of evidence concerning suicidal behaviors in Pakistan, our primary objective is to conduct a retrospective examination of suicide patterns among cases identified through medicolegal officers in Punjab from January 2018 to December 2022.

Methods

Institutional review Board of King Edward Medical university gave ethical approval of the study (Ref 106/RC/KEMU). Data needed to be extracted from the last 5 years’ hard copies of autopsy records and was de-identified. Therefore, patient consent was not applicable. In this study, we aimed to collect data from records of all districts of Punjab, requesting data with the collaboration of the Surgeon Medicolegal Punjab Office. However, we received a response from only five districts through local district medico-legal officers in Bhakkar, Okara, Nankana Sahib, Khanewal and Khushab (Fig. 1). Descriptive data was gathered from autopsies performed at the tehsil (an administrative sub-division of a district) level through a proforma completed by local medico-legal officers.

Fig. 1.

Location of study districts in Pakistan’s Punjab province

Inclusion criteria were fatal suspected suicide cases that were brought in for post-mortem examination. All other autopsy cases were excluded. Cases meeting the criteria were collected from five districts over a 5-year period, from January 2018 to December 2022. Demographic information including age, gender, place of residence, the method used, potential suicide triggers (if known), and post-mortem findings were all taken from hard copies of forensic reports and entered into the proforma based on prior research done in 2022 at Mayo Hospital Lahore and Jinnah Postgraduate Medical Center Karachi [13]. Toxicological analyses were also noted based on any available reports.

SPSS 26 was used to conduct statistical analysis. All categorical variables were estimated using frequency and percentages. The chi-square test was used to determine whether there were any statistically significant differences in suicide methods between genders and age groups.

Results

The five districts had total of 3370 autopsies done in 5 years. A total of 211 forms were received meeting our inclusion criteria of fatal suspected suicide cases (6.3% of total autopsies), of which 6 were excluded based on a lack of basic demographic information; remaining forms had the majority of information. A total of 205 autopsies due to suspected suicide were therefore identified from the five districts during the five-year data collection period. The yearly distribution of suicide autopsies was 33 in 2018, 37 in 2019, 48 in 2020, 38 in 2021, and 49 in 2022. The highest number of suicide autopsies was performed in Bhakkar district. Bhakkar had 92 suicide autopsies out of total 417autopsies (22%), Okara had 65 out of 1095 autopsies (5.9%), Khanewal had 19 out of 1057 total autopsies (1.8%), Khushab 7 out of 329 autopsies (2.1%), Nankana Sahib had 22 out of 472 total autopsies (4.7%).

Most cases (133/205, 64.9%) were under the age of thirty. About 61% of both male (65/106) and female (59/97) victims were married. Possible motives for suicides were mentioned in 129 (62.9%) reports (Table 1). These motives included domestic problems (110), poverty (9), parental refusal of permission to marry a person of choice (4), failure in love affairs (3), physical illness (2), and mental illness (1).

Table 1.

Demographic of autopsies of persons who died by suicide

Variable	N
Districtn (%)
Bhakkar	92 (44.9)
Okara	65 (31.7)
Nankana Sahib	22 (10.7)
Khanewal	19 (9.3)
Khushab	7 (3.9)
Age - Mean, (SD)	30.6 (13.1)
- Median (range)	28 (10 to 80)
Gender (%)
Male	108 (52.7)
Female	97 (47.3)
Marital status (%) (n = 201)
Single	77 (38.3)
Married	124 (61.7)
Divorced	0 (0)
Location of suicide (%) (n = 77)
Home	62 (80.5)
Outside the home	15 (19.5)
Area (%) (n = 174)
Rural	149 (72.7)
Urban	25 (12.2)
Duration of survival after the attempt (%) (n = 198)
Dead on arrival	124 (62.6)
Survival up to 24 h after the attempt	71 (35.9)
Survival up to one week after the attempt	3 (1.5)

The most commonly used suicide method was ingestion of poisonous substances (80/205, 39%) (Fig. 2) followed by hanging (75/205, 36.6%). The substances used in self-poisoning cases included paraphenylenediamine (kala pathar, a highly toxic hair dye) in 41 cases (most common poison in both rural and urban areas), aluminum phosphide (formulated as a 56% powder in 3 g ‘wheat pills’) in 13 cases, organophosphorus insecticides in four cases and a rodenticide in 1 case. The poison was not identified in 21 (26.3%) cases.

Fig. 2.

Methods of suicide noted in the autopsies

The most common method of suicide overall was ingestion of poisonous substances while the commonest method in urban areas was hanging (32%) closely followed by poisoning (28%). Significant differences were noted in method of suicide by gender and age (Table 2). Females mostly ingested poisonous substances (60/97, 61.9%) while men died from more violent methods (hanging and firearms, 64/108, 59.3%). Younger people, under 30 years, more often died from poisoning (48.1%) while older people died more commonly from hanging (48.6%).

Table 2.

Comparison of suicide methods among gender and age groups

Method of suicide	Gender N (%)		Age groups N (%)
	Male (n = 108)	Female (n = 97)	< 30 yrs (n = 133)	≥ 30 yrs old (n = 72)
Ingestion of poisonous substances	20 (18.5)	60 (61.9)	64 (48.1)	16 (22.2)
Hanging	50 (46.3)	25 (25.8)	40 (30.1)	35 (48.6)
Firearms	14 (13)	4 (4.1)	12 (9)	6 (8.3)
Drowning in river	3 (2.8)	4 (4)	5 (3.8)	2 (2.8)
Self- immolation	3 (2.8)	0 (0)	3 (2.3)	0 (0)
Jumping in front of moving train	2 (1.9)	1 (1)	1 (0.8)	2 (2.8)
Ligature Strangulation	2 (1.9)	0 (0)	1 (0.8)	1 (1.4)
Others /unclear documentation).	14 (13)	3 (3)	7 (5.3)	10 (13.9)

By considering the combined district populations of 2017 [12], with their respective annual population growth [12], suicide incidence rates of 0.31 in 2018, 0.34 in 2019, 0.43 in 2020, 0.33 in 2021 and 0.42 in 2022 per 100,000 were calculated.

Discussion

In this study of autopsies performed in five districts across the Punjab province in Pakistan, we found that self-poisoning and hanging were the most common means of suicide. Many individuals, around two-thirds, were under the age of 30. Most deaths occurred in rural areas.

The most common poisons consumed were paraphenylenediamine hair dye and aluminum phosphide fumigant tablets. Impulsivity and risk-taking behavior is common in young people. Furthermore, the motives behind suicide appear to be highly situational (e.g. domestic conflict) rather than associated with a long-term mental health condition. This young age and common use of self-poisoning suggests that many deaths were of low intent and preventable by removing highly toxic chemicals from the household [14,15]. This is consistent with literature from the region, further supporting the notion of low suicidal intent [16].

The demographic distribution of the suicide deaths in our study was similar to the few other studies that have been previously performed in Pakistan, with many deaths occurring in rural areas [11]. The mean age of suicide varied from 18 to 40 years in the previous studies [11,17]. A comprehensive study of newspaper articles conducted by Naveed and colleagues examined the patterns of suicide in Pakistan from 2019 to 2020 (similar period to our current study), with 1830 (79%) of the total suicides in Punjab province. Our finding of young age is comparable to their study in which 71.2% suicides victims were less than 30 years of age [11]. The male-to-female ratio of 1.1:1 was also comparable Naveed et al. [11] and Malik et al. [18].

The highest number of suicide deaths reported in our study are from Bhakkar which is 92 (44.9%) despite Bhakkar being the third populous district among the five districts included in our study. The population of Bhakkar was reported to be 1.65 million in 2017 [12].

The variability in percentages of suicide autopsies out of total autopsies performed (1.8-22%) in various districts could be explained by a possible higher incidence of suicide in the Bhakkar district, but it can also be possible due to relatively better documentation of autopsies in the district, as WHO repeatedly mentions under-estimation of suicide deaths in Pakistan [4].

Nearly 72.7% deaths occurred in rural areas. This appears to be in line with expected percentage, considering the rural population in these five districts varies from 72.43 to 84.21% according to 2017 census [19]. Self-poisoning was commonest in women. Hanging was the second most common method of suicide overall, with a higher number by men. Poisoning included paraphenylenediamine and aluminium phosphide ‘wheat pills’, - both are commonly used in rural settings and readily available. They were also the most common methods of poisoning in the previous studies done in Punjab [10, 11]. These two substances, plus organophosphorus insecticides, have been widely used suicide methods in Pakistan because of their ease of access, low cost, lack of regulation, and great lethality [20]. Previous research has also shown that kala pathar is more common in South Punjab while wheat pills are more common in central and northern Punjab [10]. But due to the involvement of just five districts in this study, we were unable to confirm this trend. The other methods employed for suicide included firearms, drowning in river, self-immolation, and strangulation. These results are consistent with previous data which has shown that suicide in agricultural regions of LMICs is commonly due to pesticide and other poison ingestions [8,21]. Pesticide and chemical regulation are an effective way to remove highly toxic chemicals so that they are not readily available to humans, and help prevent many deaths [21,22].

The data forms in our study were designed for a similar previous study [13]. The missing data on the forms for research may not hold a significant meaning but if the same data for a suspected suicide report is missing in official records, then it is a gross systematic negligence. One of the ways that we can make sure that this doesn’t happen is by introducing electronic forms for suicide, murder, etc. to all hospitals which, like the death forms, would have to be filled online and would then enter a national system instantaneously. The forms should include the instrument used for suicide, or identifying the specific substance ingested along with information on the quantity taken. This will make the collection of data easier and will also increase the accuracy of the data.

Toxicological screening was available for very few suicide deaths by poison. One reason could be that the toxicology labs are located far apart, and the local rural health center and District Head Quarters (DHQ) Hospitals do not have access to them. The relatives may opt out of sending the results due to the taboo associated with suicide and a fear of sending the toxicology tests to regional centers, preferring to perform the burial rites of the deceased as soon as possible. Thus, the poisons involved were identified from history only. This is one of the major drawbacks of cultural norms where suicide is taken as a taboo and the family does not want to delve deep into the cause or method of death. Cultural beliefs and taboos also mean that a large proportion of suicides likely still go unreported because until December 2022, suicide attempts were a crime in Pakistan and required a First Information Report (FIR) and report to the Police.

The possible motives of suicide were not mentioned in seventy-six cases; in 110 cases, the motive was identified as domestic problems. Other motives included poverty, parental refusal to marriage, failure in love affair and mental illness. It is noteworthy that only one case out of 129 mentioned mental illness as the motive of suicide, which could be taken as a point of increased hostility and cultural taboo toward mental health issues and their underreporting in rural areas [23]. This could be attributed to more impulsive behaviour (with low suicidal intent) in response to emotional distress brought about by a range of situational stressors including domestic conflict. But this could also be due to the fact that investigation and documentation is mostly done by non-mental health professionals who have no training in mental health issues, so they do not ask relevant questions to enquire about mental disorders.

In our study, the estimated (minimum) suicide rate varied from 0.31 to 0.43 per 100,000 showing relative increasing trend (0.31 per 100,00 in 2018 to 0.42 per 100,000 population in 2022). This was less than many previous autopsy studies done in large centers like Lahore (0.87), Faisalabad (1.12) and Karachi, Sindh (1.150) [7] but larger than a study done in Peshawar, Khyber Pakhtunkhwa province (0.21) [7]. When we compare the suicide incidence rate by autopsy studies to approximate suicide rate in Pakistan by WHO (8.9) [2], it is easy to see the severe under-estimation and under-reporting of suicide when estimating rates by autopsy studies.

There were limitations to our study. Apart from receiving data from only 5 districts (rather than all Punjabi districts), there was some information missing in many forms. In the suicide deaths by poisoning, only a few had toxicology samples sent to laboratories to confirm identity of the poison, with the majority reported only on basis of history provided. The deaths by firearms had little to no data recorded on the forms and there was missing information regarding the number of bullets and wound analyses.

However, there were also significant strengths of our current study. This is the first study in which five districts dispersed across Punjab were included. Previous research mostly focused on Lahore district in the Punjab; the districts studied have never been researched before to our knowledge. The study gives a first idea of demographic distribution of suicide cases and methods used from officially obtained data. This can help to understand the pattern of suicide deaths and formulate policies based on local data to decrease the suicide related deaths in the areas. There has been some research conducted in a few districts of Punjab but none that includes all districts [7]. The most efficient way in our opinion would be to initiate an online form that would be made mandatory for doctors conducting autopsy of the deceased. That would make the entire data easily accessible and shed light on the prevalence and demography of the local population and their mental health issues.

Conclusions

Our study highlights the need of official reporting of suicide deaths and the different methods used by people in rural and urban population of Punjab. The research is done in Districts of Punjab with no previous data of suicides ever reported and despite its short comings, like lack of proper chemical examinations of toxicology samples or laboratory tests done in all cases of suspected suicides, it still shows the demographic distribution of suicide cases in these districts of Punjab. The most common method in our study, ingestion of poisonous substances, is in line with all other studies done in suicide methods and can be used by government towards initiating pesticide and chemical regulations.

The WHO has started an initiative termed the 2030 Global Mental Health Action Plan, in which they aim to reduce the suicide deaths by one third [24]. But in countries like Pakistan, this is a long way off because suicides are not readily reported due to cultural taboos and when reported, are not properly processed. De-criminalization of suicide is a good first step, but the country has a long way to go. There is need for a national suicide registry and official reporting of suicide deaths on a national level so we can organize an effective suicide prevention strategy by making a hierarchy of practical steps. Furthermore, in line with WHO’s LIVE LIFE initiative for suicide prevention, programs aimed at building socio-emotional life-skills and resilience among young people should be actively pursued at national level. These are important to ensure young people are equipped to manage life adversities such as domestic conflict [15].

In addition, as recommended by the WHO and Food and Agriculture Organization (FAO) [25,26], pesticide and chemicals regulation to remove 56% 3 g tablet of aluminium phosphide and paraphenylene-diamine from public use, as has been done in India [27] and Nepal [28] and called for in Tunisia [29], respectively; would rapidly reduce the number of deaths in Pakistan from self-poisoning [30]. Broader interventions to address domestic violence also appear to be an important priority in Pakistan and should be included in suicide prevention strategies, especially given the strong global evidence on the association between domestic violence and suicide [31] and the high numbers of suicide among women in Pakistan.

Abbreviations

WHO

World Health Organization

LMIC

LMIC Low-and Middle-Income Countries

Author contributions

ARM & NI were responsible for designing the study, data collection and coordination. FA & MA analyzed data and helped in writing the initial manuscript draft. ME has been actively involved in further refining the study, addition of figures and contributed to subsequent revisions of the manuscript. All authors read and approved the final manuscript.ARM, NI, FA and MA institutions belong to Lahore. ME institution is in Edinburgh, United Kingdom.

Funding

None.

Data availability

All data generated or analysed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

Institutional review Board IRB Approval from King Edward Medical university (Ref 106/RC/KEMU).

Consent for publication

Not applicable as data is extracted from retrospective records of autopsies anonymously.

Competing interests

The authors declare no competing interests.