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. 2022 Apr 1;9:181–192. doi: 10.1017/gmh.2022.20

Depression and suicidal behavior in South Asia: a systematic review and meta-analysis

S M Yasir Arafat 1,✉, Tamkeen Saleem 2, Vikas Menon 3, Syeda Ayat-e-Zainab Ali 2, Anuradha Baminiwatta 4, Sujita Kumar Kar 5, Hasina Akter 6, Rakesh Singh 7
PMCID: PMC9806989  PMID: 36618741

Abstract

Background

Estimates of depression in suicidal behavior in South Asia would help to formulate suicide prevention strategies in the region that hasn't been assessed yet.

Objectives

We aimed to systematically assess the prevalence of depression in fatal and non-fatal attempts of suicide in eight South Asian countries.

Methods

We searched Medline, Embase, and PsychINFO by specific search terms to identify articles assessing depression in fatal and non-fatal attempts of suicide in South Asian countries published between 2001 and 2020. Two separate meta-analyses were conducted for fatal and non-fatal attempts. Due to the high heterogeneity of studies (96–98%), random-effects models were used to calculate pooled prevalence rates.

Results

A total of 38 studies was identified from five south Asian countries (India [27], Pakistan [6], Sri Lanka [3], Nepal [1], and Bangladesh [1]). The majority of studies (n = 27) were published after 2010. Twenty-two studies reported non-fatal attempts, and sixteen reported suicide. The prevalence of depression among non-fatal attempts ranged from 14% to 78% where the pooled prevalence rate was 32.7% [95% CI 26–39.3%]. The prevalence of depression among suicides ranged from 8% to 79% where the pooled prevalence estimate was 37.3% [95% CI 26.9–47.6%].

Conclusions

This review revealed the pooled prevalence of depression among fatal and non-fatal suicidal attempts in South Asian countries, which seems to be lower when comparedto the Western countries. However, a cautious interpretation is warranted due to the heterogeneity of study methods, sample size, and measurement of depression.

Key words: Depression, non-fatal attempt, self-harm, South Asia, suicide

Introduction

Suicide is a global public health issue (World Health Organization, 2021). The World Health Organization (WHO) estimated that just over 700 000 deaths happened by suicide worldwide in 2019, representing an annual global age-standardized suicide rate of 9 per 100 000, being the fourth-leading cause of death among 15–29-year-olds (WHO, 2021). It is the end result of a complex interaction between several risk factors which may include biological, personal, social, psychological, cultural, and environmental factors, but psychiatric disorders are one of the most crucial risk factors (WHO, 2014; Zalsman et al., 2016; Arafat and Kabir, 2017). Estimations indicate that about 90% of people who die by suicide experience some form of psychiatric illness (Cavanagh et al., 2003; Milner et al., 2013; Cho et al., 2016; Zalsman et al., 2016; Arafat and Kabir, 2017). Among psychiatric disorders, depression is the most common risk factor for suicides (Malakouti et al., 2015; Arafat and Kabir, 2017).

South Asia is a suicide-dense area with a handful of studies assessing the relationship between depression and suicidal behavior. South Asia represents approximately one-quarter (23%) of the global population, and one-fifth of the mental health cases live here (Bishwajit et al., 2017). A recent systematic review conducted by Arafat and colleagues assessed psychiatric disorders from psychological autopsy studies in the WHO-South East Asia (SEA) region; however, the proportion of depression was not delineated (Arafat et al., 2022). Another systematic review conducted by Knipe et al. (2019) studied psychiatric morbidities in low-and-middle-income countries, which also lacked calculation of the prevalence of depression in suicidal behavior. One systematic review assessed depression in suicidal behavior in WHO-SEA countries that included papers from 1956 to 2016 (Ahmed et al., 2017). The review included articles published over a wide duration, but it assessed only 19 articles over the 60-year duration in the eleven countries of the WHO-SEA region, indicating a sporadic distribution of papers. Additionally, the authors considered the articles where depression was measured without any objective instruments in the same manner as articles where it was measured with objective instruments, even though this distinction was clearly stated. Also, a meta-analysis was not performed. Given such limitations in previous literature, we aimed to assess the prevalence of depression in suicidal behavior in the South Asian countries (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) based on recent updates (2001–2020). We also aimed to estimate the pooled rates of depression among fatal and non-fatal suicidal attempts, and categorizing studies based on how depression was measured, viz. with/without objective instruments.

Methods

Search strategy

We searched Medline, Embase, and PsychINFO by specific search terms for the identification of articles assessing depression in suicidal behavior in South Asia. The details of the search strategy are mentioned in online Supplementary file 1 and the protocol was registered in advance (PROSPERO 2021 CRD42021285207). We included the articles published between 2001 and 2020 irrespective of the period of data collection. We also did a hand search of recently published systematic reviews to ensure the inclusion of a maximum number of articles (Ahmed et al., 2017; Knipe et al., 2019; Arafat et al., 2022). The stepwise search details are mentioned in Fig. 1. Two separate authors screened the articles independently and the third opinion was sought if any ambiguity appeared.

Fig. 1.

Fig. 1.

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PRISMA 2009 flow diagram.

Inclusion criteria

Original articles, studies with quantitative estimates, published in the English language, and articles available in full-text were included.

Exclusion criteria

We excluded articles having samples from the veterans, and articles with qualitative outcomes. Articles from multiple country data and multiple articles from the same project were excluded. Any type of review, editorial, erratum, letters without primary data were excluded. Articles from media reports were excluded.

Data extraction

The search identified 38 articles from five South Asian countries (Bangladesh [1], India [27], Nepal [1], Pakistan [6], and Sri Lanka [3]). Two authors extracted the data independently and a third author cross-checked the data extraction.

Quality assessment

The methodological quality of each article included in the systematic review was assessed. Two authors independently evaluated the risk of bias for the research papers based on non-randomized studies. The tool applied for quality assessment was a modified version of the Newcastle-Ottawa Scale (NOS). The scale evaluated each article on the following aspects: (1) sample representativeness and size (2) comparability between respondents and non-respondents (3) ascertainment of depressive or suicidal symptoms (4) thoroughness of descriptive statistics reporting (Rotenstein et al., 2016). All components of the scale are to be summated to generate a total score for the risk of bias. The total score ranges from 0 to 5.The research studies were evaluated to be at low risk of bias (⩾3 points) or high risk of bias (<3 points).

Data analysis

The effect size of interest in the present meta-analysis was the prevalence of depression. Pooled prevalence rates were calculated separately for fatal and non-fatal attempts. The Meta and Metafor packages in the R environment were used for the calculation of pooled effects, heterogeneity statistics, subgroup analysis, publication bias analysis, and sensitivity analysis. Heterogeneity among studies was examined using the I2 statistic and Cochran'sQ test. Due to significant heterogeneity, random-effects models were used for the meta-analysis. Pooled estimates were calculated using the inverse variance method of random effects models andreported as proportions with 95% confidence intervals. Publication bias was examined by visual inspection of funnel plots, as well as the rank-correlation and Egger's tests for funnel plot asymmetry; a non-significant p value (>0.05) in the rank-correlation and Egger's tests indicates low publication bias. Subgroup analysis was performed by dividing the studies based on the use of standard methods for assessing depression. In subgroup analysis, a common between-study variance component was assumed due to the small number of studies in each subgroup, and tau-squared was pooled across the groups.

Ethical aspects

We reviewed secondary data from publicly available articles. Therefore, no institutional review board approval was sought to conduct the study.

Results

Distribution of the studies

In this systematic review, 38 studies fulfilled the eligibility criteria (Fig. 1). The highest number of studies were identified from India(n = 27), followed by Pakistan (n = 6), Sri Lanka (n = 3), Bangladesh (n = 1), and Nepal (n = 1). The majority of studies (n = 27) were published after 2010. Out of the 38 studies, 22 reported on non-fatal attempts, and 16 reported on suicides.

Characteristics of studies on non-fatal attempts

The characteristics of studies among non-fatal attempts are presented in Table 1. Studies from India (n = 17), Pakistan (n = 4), and Sri Lanka (n = 1) reported on depression among non-fatal attempts. The sample size of studies ranged from 27 to 1159 and the total number of non-fatal attempts in the 22 studies was 4597. The percentage of males in these samples ranged from 25% to 78%. Mean age was reported in only seven studies, and the age range was reported in six studies. Whether the study population was from a rural or urban area could be identified in 14 studies: five studies were based on rural populations, four studies were on urban population and five had mixed rural/urban populations (Table 1).

Table 1.

Characteristics of studies of non-fatal attempts

Study no. Study Country Place of study Study design Depression assessment method Rural/Urban Sample size Male: Female ratio Mean (s.d.) age, [range] Prevalence of depression (%) Risk of bias
1 Chandrasekaran and Gnanaselane (2005) India Pondicherry MADRS 341 0.81:1 26.1 (±9.3) 31 Low
2 Kumar et al. (2006) India Pondicherry MADRS Rural 203 1.05:1 [16–65] 29.56 Low
3 Parkar et al. (2006) India Mumbai Cross-sectional SCID-I Urban 196 1.1:1 43.9 Low
4 Syed and Khan (2008) Pakistan Karachi retrospective descriptive study Clinical diagnosis 69 0.56:1 18.8 Low
5 Bansal et al. (2011) India Panjab Cross-sectional ICD-10 Urban 100 1.56:1 46 Low
6 Bansal and Barman (2011) India Bathinda Cross-sectional ICD-10 Urban 100 0.72:1 36 Low
7 Yadiyal and Aruna (2011) India Mangalore Cross-sectional SCID-I 51 1.12:1 [18–65] 33.33 High
8 Vishnuvardhan and Saddichha (2012) India Bangalore SCID-I 100 0.92:1 14 Low
9 Rao et al. (2013) India Cross-sectional MINI plus Rural and urban 100 1.08:1 27.31 (±8.68) 35 Low
10 Chowdhury et al. (2013) India Sundarban Prospective study SCID 89 0.34:1 14.6 Low
11 Tahir et al. (2013) Pakistan Mianwali Population-based survey Rural and urban 104 3.5:1 33 Low
12 Krishna et al. (2014) India Mysore Cross-sectional MINI Rural 200 1.02:1 29.1 (±10.5) [18–70] 15.5 Low
13 Rajapakse et al. (2014) Sri Lanka Peradeniya PHQ-9 Urban 949 0.79:1 51.1 Low
14 Kosaraju et al. (2015) India Hyderabad Prospective study Clinical diagnosis Rural 36 0.8:1 [16–70] 38.9 High
15 Halder and Mahato (2016) India Kolkata Cross-sectional ICD-10 Urban, semi-urban and rural 100 0.38:1 23.56 (±6.38) [15–40] 41 Low
16 Husain et al. (2019) Pakistan Karachi BDI 221 0.45:1 78.3 Low
17 Reuben et al. (2020) India Salem Case–control HDRS Rural and urban 100 1.08:1 27.31 (±8.68) 60 Low
18 Khan and Ayub (2020) Pakistan Peshawar Prospective study 102 0.61:1 14.8 Low
19 Kar (2010) India Orissa Cross-sectional ICD-10 Rural 149 0.77:1 24.8 Low
20 Kumar et al. (2015b, 2015a) India Kerala Non-Experimental descriptive ICD-10 Rural 1159 0.99:1 68.89 (±4.74) (older), 29.34 (±10.70) (younger) 24.42 Low
21 Ramdurg et al. (2011) India New Delhi Prospective study ICD-10 Rural and urban 27 1.25:1 31.5 (±11.62) [16–64] 19 Low
22 Sahoo et al. (2016) India Jamshedpur Cross sectional 101 0.71:1 30.7 Low
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MADRS, Montgomery-Asberg Depression Rating Scale; SCID, Structured Clinical Interview for DSM-IV Axis I Disorders; ICD, International Classification of Diseases; MINI, Mini-International Neuropsychiatric Interview; PHQ, Patient Health Questionnaire; BDI, Beck Depression Inventory; HDRS, Hamilton Depression Rating scale.

The use of a structured diagnostic interview or validated rating scale to assess depression was reported in 17 studies. Diagnostic interviews used International Classification of Diseases (ICD) diagnostic criteria (n = 6), Diagnostic and Statistical Manual ofMental Disorders (DSM) criteria (n = 4), and the Mini International Neuropsychiatric Interview (n = 2); in two studies, a clinical diagnostic interview had been used, but the exact type of criteria was not reported. Studies used several rating scales namely, Montgomery Asberg Depression Rating Scale (n = 2), Beck Depression Inventory (n = 1), Hamilton Depression Rating scale (n = 1) and Patient Health Questionnaire (PHQ-9) (n = 1). A standard method (structured interview or rating scale) was not reported in three studies.

Prevalence of depression among non-fatal attempts

The prevalence of depression among non-fatal attempts ranged from 14% to 78%. There was significant heterogeneity between the studies [I2 = 95.9% (94.8%; 96.8%) and Cochran's Q = 515.8, df = 21, p < 0.001]. Therefore, a random-effects model was used for estimating the pooled prevalence of depression. The pooled estimate for the prevalence of depression among non-fatal attempts was 32.7% [95% CI 26–39.3%] (Fig. 2).

Fig. 2.

Fig. 2.

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Pooled estimate for the prevalence of depression among non-fatal attempts of 22 studies.

A subgroup analysis was performed to test if the prevalence rate was different for studies that used a standard method of assessment and those that did not (Fig. 2). The pooled prevalence in studies that reported a standard method (k = 19) was 33.8%; and in studies that did not report a standard method (k = 3), the prevalence was 25.8%. This difference was, however, not statistically significant (Q = 0.64, df = 1, p = 0.42). A sensitivity analysis was performed by excluding studies with a high risk of bias (n = 2) from the meta-analysis; the pooled prevalence did not change remarkably [32.5% (95% CI 25.2–39.7%)].

Characteristics of studies on suicide

The characteristics of studies on suicide are presented in Table 2. Studies from India (n = 10), Pakistan (n = 2), Sri Lanka (n = 2), Bangladesh (n = 1) and Nepal (n = 1) reported the presence of depression among people who died by suicide. The sample size of studies ranged from 27 to 857 and the total number of suicides in the 16 studies was 2509. The percentage of males in these samples ranged from 7.7% to 83%. Mean age was reported in six studies and age range was reported in seven studies. Whether the study population was from a rural or urban area could be identified in eight studies: One study was based on rural populations, two studies were on urban populations and five had mixed rural/urban populations. Nine studies reported using a standard diagnostic interview or validated rating scale to assess depression; a standard method was not reported in seven studies. Diagnostic interviews were based on ICD diagnostic criteria (n = 4) and DSM (n = 4). In one study, a rating scale (PHQ-9) had been used.

Table 2.

Characteristics of studies of suicides

Study no. Study Country Place of study Study design Depression assessment method Rural/Urban Sample size Male: Female ratio Mean (±s.d.) age, [range] Prevalence of depression (%) Risk of bias
1 Khan et al. (2005) India Case series psychological autopsy Urban and rural 50 1.38:1 [15–35] 10 Low
2 Kanchan and Menezes (2008) India Manipal Retrospective study Rural 137 2.8:1 [16–82] 38.7 Low
3 Khan et al. (2008) Pakistan Karachi Case–control psychological autopsy ICD-10 Urban 100 4.88:1 79 Low
4 Abeyasinghe and Gunnell (2008) Sri Lanka Anuradhapura, Kurunegala; Hambantota Case-series psychological autopsy ICD-10 372 3.76:1 [10–94] 48.4 Low
5 Samaraweera et al. (2008) Sri Lanka Ratnapura Case-series psychological autopsy ICD-10 27 2.37:1 43 [15–74] 37 High
6 Chavan et al. (2008) India Chandigarh Case series psychological autopsy Rural, suburban, urban 101 1.34:1 11.9 Low
7 Manoranjitham et al. (2010) India Kaniyambadi Block, Vellore District, Case–control psychological autopsy SCID (DSM-III-R) Rural 100 1.43:1 42.24 (±20.69) 2 Low
8 Srivastava (2013) India Goa Case series psychological autopsy ICD-10 urban, rural 100 2.33:1 54 Low
9 Tanna et al. (2013) India Gujarat Retrospective study 110 1.07:1 8 Low
10 Kumar et al. (2015b, 2015a) India Lucknow Retrospective study 857 0.08:1 33.74 (±11.64) 28.57 Low
11 Bhise and Behere (2016) India Wardha Case–control psychological autopsy SCID-I (DSM-IV-TR) 98 8.8:1 37.7 Low
12 Hagaman et al. (2017) Nepal Jumla & Kathmandu Mixed method psychological autopsy study PHQ-9 Rural and urban 39 1.16:1 32.9 (±17.55) [14–79] 38.5 Low
13 Sandeep et al. (2017) India Bhopal Retrospective study Rural and urban 200 1.56:1 39.5 Low
14 Abdullah et al. (2018) Pakistan Khyber Pakhtunkhwa Case series psychological autopsy DSM-5 criteria 63 1.52:1 22.1 (±3.08) 60.3 Low
15 Narayanan et al. (2020) India Kerala cross-sectional 55 [10–19] 50.96 High
16 Arafat et al. (2021b, 2021a) Bangladesh Dhaka Case–control psychological autopsy SCID-I Urban 100 0.96:1 26.30 (±12.36) [9–75] 44 Low
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SCID, Structured Clinical Interview for DSM-IV Axis I Disorders; ICD, International Classification of Diseases; PHQ, Patient Health Questionnaire; DSM, Diagnostic Statistic Manual.

Prevalence of depression among suicide

The prevalence of depression among suicides in individual studies ranged from 8% to 79%. There was significant heterogeneity between the studies [I2 = 98.2% (97.7%; 98.5%) and Cochran's Q = 812.62, df = 15, p < 0.0001]. Therefore, a random-effects model was used for estimating the pooled prevalence of depression. The pooled estimate for the prevalence of depression among suicide attempters was 37.3% [95% CI 26.9–47.6%] (Fig. 3).

Fig. 3.

Fig. 3.

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Pooled estimate for the prevalence of depression among suicides of 16 studies.

A subgroup analysis was performed to test if the prevalence rate was different for studies that used a standard method of assessment and those that did not (Fig. 3). The pooled prevalence in studies that reported a standard method (k = 9) was 44.5%; and in studies that did not report a standard method (k = 7), the prevalence was 28.2%. This difference was not statistically significant (Q = 2.76, df = 1, p = 0.097).A sensitivity analysis was performed by excluding studies with a high risk of bias (n = 2) from the meta-analysis; the pooled prevalence did not change remarkably [36.3% (95% CI 24.8–47.9%)].

Publication bias

The funnel plot for studies on non-fatal attempts is shown in Fig. 4. Egger's test of funnel plot asymmetry (Z = 0.189, p = 0.85) and rank correlation test (Kendall's tau = 0.264, p = 0.091) both indicate that the funnel plot is not significantly asymmetrical, suggesting low publication bias for the studies. The funnel plot for studies on suicides is shown in Fig. 5. Egger's test of funnel plot asymmetry (Z = 1.46, p = 0.145) and rank correlation test (Kendall's tau = 0.017, p = 0.965) both indicate that the funnel plot is not significantly asymmetrical, suggesting low publication bias for the studies.

Fig. 4.

Fig. 4.

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Funnel plot for studies on non-fatal attempts of 22 studies.

Fig. 5.

Fig. 5.

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Funnel plot for studies on suicide.

As per the modified Newcastle Ottawa Quality assessment scale, four studies were found to have a high risk of bias (score < 3) and thirty-four were at low risk (score ⩾ 3). Among the reviewed studies, the Newcastle Ottawa Quality assessment scale score was between 0 and 5.Eight studies (n = 8, 20%) had high methodological quality, while the rest were of moderate (n = 19, 47.5%) and low quality (n = 13, 32.5%).

Discussion

Major findings of the review

South Asia is a suicide-dense region having a higher rate of suicide than the global average (WHO, 2021). Additionally, the role of psychiatric disorder as a risk factor has been under-studied in the region, albeit, the prevalence of the mental disorder among suicides varies from the West (Arafat et al., 2022). We aimed to assess depression among the fatal and non-fatal attempts of suicide in South Asian countries over the last two decades to see the recent scenario based on a search in Medline, Embase, and PsychINFO. To our knowledge, no prior systematic review has focused on estimating the prevalence of depression among those with suicidal behavior in South Asia. Our main findings revealed that the prevalence of depression among non-fatal attempts in 22 eligible studies ranged from 14% to 78%; and the corresponding figures for depression among suicides in 16 eligible studies ranged from 8% to 79%. The pooled prevalence estimate for depression among those with non-fatal attempts and suicide decedents was 32.7% and 37.3%, respectively. Findings from sub-group analysis revealed a relatively higher prevalence of depression in those studies where standard instruments were used, compared to studies where no standard instruments were utilized. This may indicate a possible under-reporting of depressive symptoms, and possibly, a higher stigma toward both psychiatric disorder and suicidal behavior. However, these subgroup differences did not reach statistical significance, likely due to the small number of studies in subgroups.

Ahmed et al. (2017), in their systematic review from eleven WHO-SEA regions, noted a wide range in prevalence rates of depression among suicides (6.9–51.7%) and non-fatal attempts (22–59.7%) similar to our findings. However, no meta-analysis was performed. Additionally, the authors searched databases through 60 years (1956–2016) and identified only 19 articles, whereas our study revealed recent estimates over the last 20 years from a higher number of studies and pooled the data in a meta-analysis. A previous review on psychiatric morbidity among patients with self-harm behavior revealed a pooled prevalence rate of 49.4% for depression in this group, which was the highest among all mental disorders (Hawton et al., 2013); our figures are relatively lower (32.7%). This difference may indicate a lower prevalence of depression in South Asian countries compared to the West among patients presenting with self-harm. On a similar note, authors who focused on synthesizing evidence from low- and middle-income countries found that mood disorders (including all ICD-10 mood disorder categories) were the most prevalent psychiatric disorder in both fatal and non-fatal suicidal behavior; the pooled prevalence estimates were 25 and 21%, respectively (Knipe et al., 2019). Nevertheless, separate pooled estimates for depression were not computed in that review. Another recent review of psychological autopsy studies also revealed a lower proportion of psychiatric disorders among suicides in the five WHO-SEA countries (Arafat et al., 2022). Two other reviews of psychological autopsy studies are available; one of them noted that depression was the most common mental illness among those who died by suicide but did not provide separate prevalence estimates for depression (Cavanagh et al., 2003). The other was a larger review that investigated geographical variations in the prevalence of psychiatric morbidity in suicide (Cho et al., 2016). Here, the authors reported a 51% prevalence rate for depressive disorder (including major depression and dysthymia) among suicide decedents; these figures are higher than what we have obtained, and the variations are likely due to geographical and methodological variations in studies. Most of these reviews primarily included research from high-income countries where mental illness is a major vulnerability factor as well as a driver for suicide.

Only four (Samaraweera et al., 2008; Yadiyal and Aruna, 2011; Kosaraju et al., 2015; Narayanan et al., 2020) of the 38 studies included in this review had a high risk of bias according to the assessment tool. The majority of the studies on non-fatal attempts (17 out of 22) used a structured assessment tool; in contrast, only 9 among 16 studies on suicide used this approach. The use of a structured assessment tool may be superior to unstructured interviews for generating a psychiatric diagnosis; this may be of particular relevance to the South Asian region, which is dominated by low- and middle-income countries where there is a considerable treatment gap for mental illness and psychiatric disorders are, often, under-diagnosed and undertreated (Naveed et al., 2020). This is also reflected in the quality assessment results, where many studies showed bias with regard to the ascertainment of exposure.

Significant heterogeneity (96–98%) was noted among study results, with wide-ranging prevalence estimates of depression among suicides and attempted suicide. Similar rates of heterogeneity have been noted in prior systematic reviews that investigated similar research questions (Hawton et al., 2013; Knipe et al., 2019). These differences can be likely attributed to two factors. Firstly, they may reflect real differences in depression-related morbidity among those exhibiting suicidal behavior. Secondly, they may reflect differences in the way the study was designed, conducted, interpreted, and analyzed. A deeper examination of the numbers suggests that the latter possibility may be relevant because Indian studies dominated the included literature and wide within-country variations were noted in prevalence rates. Variations between studies in definitions used for suicidal behavior may also have contributed to the observed heterogeneity. Future studies should use standardized instruments, recruit consecutive cases, and use standard definitions for defining cases to enhance the comparability of findings.

Our findings have important implications for suicide prevention in the region. In high-income countries, where a higher prevalence of depression is seen among suicide decedents (Cho et al., 2016), it follows that suicide prevention efforts need to focus on strengthening clinical services and care delivery bundles (Arafat et al., 2022). However, in the South Asian region, with a lower prevalence of depression, prevention of suicide must focus on a range of non-clinical contributory factors. These may include socio-economic determinants of suicide such as poverty (Iemmi et al., 2016; Arafat et al., 2021b, 2021a), gender inequality (Devries et al., 2011), and financial insecurity (Knipe et al., 2015). Targeting these factors will require a community-based suicide prevention approach with a multimodal focus: adequate insurance and welfare measures for alleviating poverty and improving employment, restricting access to lethal means, improving media portrayal of suicide, and utilization of community resources to enhance social connectedness are some of the potentially beneficial strategies. The latter strategy of increasing civic participation to link service providers to the needy has shown encouraging results in Japan and may be trialed elsewhere (Motohashi et al., 2007; CSRP Newsletter, 2009). On the other hand, the diagnosis of depression could be under-reported in suicidal behavior due to criminal status (Afghanistan, Bangladesh, Pakistan), stigma, low mental health literacy, poor mental health services coverage among suicides, a lower proportion of mental health personnel (Arafat et al., 2021b, 2022). At a policy level, given the relatively lower burden of depression among both attempters and those who died by suicide, suicide prevention efforts in South Asia may need to focus on locally relevant socio-economic stressors (such as poverty, unemployment), societal factors (such as rapid urbanization), and their interaction with depression and psychiatric morbidity. Such an approach will assist in modifying various factors in the causal pathway to suicide in these settings. Local and regional mental health advocacy groups like SAARC Psychiatric Federation could lead the countries to create awareness and reduce stigma related to suicide and depression (mental illness), further investigations to identify whether any under-reporting of depression would be benefitted.

Strength and limitations of the study

This is the first systematic review assessing depression and suicidal behavior in South Asia during the immediate past two decades and creating pooled prevalence rate for depression. We searched three major databases (Medline, Embase, and PsychINFO). However, several limitations should be considered while generalizing the study results. Firstly, there is heterogeneity in the study methods, sample size, sampling frame and instruments that may affect the prevalence of depression from context to context. Secondly, the majority of the studies (27/38) were identified from India which would also affect the generalizability of the results.

Conclusions

This review revealed the pooled prevalence of depression among fatal and non-fatal suicidal attempts in five South Asian countries, which seems to be lower when compared to the Western countries. Additionally, a relatively higher prevalence of depression was noted among studies using standard instruments indicating possible underreporting and stigma. A cautious interpretation of these findings is warranted due to substantial methodological and statistical heterogeneity noted in the analysis. Nevertheless, our findings have important implications for suicide research and prevention efforts in the region; most importantly, it highlights the need for a multimodal approach to suicide prevention that targets a range of contributory factors apart from mental health morbidity.

Acknowledgements

None.

Supplementary material

For supplementary material accompanying this paper visit https://doi.org/10.1017/gmh.2022.20.

S2054425122000206sup001.docx (13.2KB, docx)

click here to view supplementary material

Author contributions

Conceptualization: S M Yasir Arafat, T. Saleem. Data curation: S M Yasir Arafat, Hasina Akter, Rakesh Singh. Formal analysis: Anuradha Baminiwatta, Vikas Menon. Investigation: S M Yasir Arafat. Methodology: S M Yasir Arafat. Project administration: S M Yasir Arafat. Supervision: S M Yasir Arafat. Validation: S M Yasir Arafat. Writing – Original draft preparation: All authors. Writing – Review & editing: All authors. All authors have read and approved the final version of the manuscript.

Conflict of interest

The authors declare there is no conflict of interest.

Transparency statement

The lead author S M Yasir Arafat affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author.

References

  1. Abdullah M, Khalily MT, Ahmad I and Hallahan B (2018) Psychological autopsy review on mental health crises and suicide among youth in Pakistan. Asia Pacific Psychiatry 10, e12338. [DOI] [PubMed] [Google Scholar]
  2. Abeyasinghe R and Gunnell D (2008) Psychological autopsy study of suicide in three rural and semi-rural districts of Sri Lanka. Social Psychiatry and Psychiatric Epidemiology 43, 280–285. [DOI] [PubMed] [Google Scholar]
  3. Ahmed HU, Hossain MD, Aftab A, Soron TR, Alam MT, Chowdhury MWA and Uddin A (2017) Suicide and depression in the World Health Organization South-East Asia Region: a systematic review. WHO South-East Asia J Public Health 6, 60–66. [DOI] [PubMed] [Google Scholar]
  4. Arafat SMY and Kabir R (2017) Suicide prevention strategies: which one to consider? South East Asia Journal of Public Health 7, 1–5. [Google Scholar]
  5. Arafat SMY, Mohit MA, Mullick MSI, Kabir R and Khan MM (2021a) Risk factors for suicide in Bangladesh: case–control psychological autopsy study. BJPsych Open 7, e18. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Arafat SMY, Khan MAS, Knipe D and Khan MM (2021b) Population attributable fractions of clinical and social risk factors for suicide in Bangladesh: finding from a case–control psychological autopsy study. Brain and Behevior 11, e2409. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Arafat SMY, Menon V, Varadharajan N and Kar SK (2022) Psychological autopsy studies of suicide in South East Asia. Indian Journal of Psychological Medicine 44, 4–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Bansal PD and Barman R (2011) Psychiatric morbidity and the socio-demographic determinants of deliberate self harm. Journal of Clinical and Diagnostic Research 5, 601–604. [Google Scholar]
  9. Bansal P, Gupta A and Kumar R (2011) The psychopathology and the socio-demographic determinants of attempted suicide patients. Journal of Clinical and Diagnostic Research 5, 917–920. [Google Scholar]
  10. Bhise MC and Behere PB (2016) Risk factors for farmers'suicides in central rural India: matched case–control psychological autopsy study. Indian Journal of Psychological Medicine 38, 560–566. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Bishwajit G, O'Leary DP, Ghosh S, Yaya S, Shangfeng T and Feng Z (2017) Physical inactivity and self-reported depression among middle-and older-aged population in South Asia: world health survey. BMC Geriatrics 17, 1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Cavanagh JT, Carson AJ, Sharpe M and Lawrie SM (2003) Psychological autopsy studies of suicide: a systematic review. Psychological Medicine 33, 395–405. [DOI] [PubMed] [Google Scholar]
  13. Chandrasekaran R and Gnanaselane J (2005) Correlates of suicidal intent in attempted suicide. Hong Kong Journal of Psychiatry 15, 118–122. [Google Scholar]
  14. Chavan BS, Singh GP and Kaur J (2008) Psychological autopsy of 101 suicide cases from northwest region of India. Indian Journal of Psychiatry 50, 34–38. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Cho SE, Na KS, Cho SJ, Im JS and Kang SG (2016) Geographical and temporal variations in the prevalence of mental disorders in suicide: systematic review and meta-analysis. Journal of Affective Disorder 190, 704–713. [DOI] [PubMed] [Google Scholar]
  16. Chowdhury AN, Banerjee S, Brahma A, Hazra A and Weiss MG (2013) Sociocultural context of suicidal behaviour in the Sundarban region of India. Psychiatry Journal 2013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. CSRP Newsletter (2009) Cherishing Life. Nourishing Hope. Centre for Suicide Research and Prevention, Faculty of Social Sciences, The University of Hong Kong. Cherishing life, nourishing hope. CSRP Newsletter, February 2009. Available at http://chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/viewer.html?pdfurl=https%3A%2F%2Fcsrp.hku.hk%2Fwp-content%2Fuploads%2F2015%2F09%2FFeb2009.pdf&clen=6093439&chunk=true (Last Accessed 9 November 2021).
  18. Devries K, Watts C, Yoshihama M, Kiss L, Schraiber LB, Deyessa N, et al. (2011) Violence against women is strongly associated with suicide attempts: evidence from the WHO multi-country study on women's health and domestic violence against women. Social Science and Medicine 73, 79–86. [DOI] [PubMed] [Google Scholar]
  19. Hagaman AK, Khadka S, Lohani S and Kohrt B (2017) Suicide in Nepal: a modified psychological autopsy investigation from randomly selected police cases between 2013 and 2015. Social Psychiatry and Psychiatric Epidemiology 52, 1483–1494. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Halder S and Mahato AK (2016) Socio-demographic and clinical characteristics of patients who attempt suicide: a hospital-based study from Eastern India. East Asian Archives of Psychiatry 26, 98–103. [PubMed] [Google Scholar]
  21. Hawton K, Saunders K, Topiwala A and Haw C (2013) Psychiatric disorders in patients presenting to hospital following self-harm: a systematic review. Journal of Affective Disorder 151, 821–830. [DOI] [PubMed] [Google Scholar]
  22. Husain MO, Umer M, Taylor P, Chaudhry N, Kiran T, Ansari S, Chaudhry IB and Husain N (2019) Demographic and psychosocial characteristics of self-harm: the Pakistan perspective. Psychiatry Research 2019, 201–206. [DOI] [PubMed] [Google Scholar]
  23. Iemmi V, Bantjes J, Coast E, Channer K, Leone T, McDaid D, et al. (2016) Suicide and poverty in low-income and middle-income countries: a systematic review. The Lancet. Psychiatry 3, 774–783. [DOI] [PubMed] [Google Scholar]
  24. Kanchan T and Menezes RG (2008) Suicidal poisoning in Southern India: gender differences. Journal of Forensic and Legal Medicine 15, 7–14. [DOI] [PubMed] [Google Scholar]
  25. Kar N (2010) Profile of risk factors associated with suicide attempts: a study from Orissa, India. Indian Journal of Psychiatry 52, 48–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Khan I and Ayub S (2020) A correlational study of hopelessness and suicidal intent in patients presenting to accident and emergency department of a tertiary care hospital after attempted suicide. Journal of Medical Sciences 28, 210–213. [Google Scholar]
  27. Khan FA, Anand B, Devi MG and Murthy KK (2005) Psychological autopsy of suicide—a cross-sectional study. Indian Journal of Psychiatry 47, 73–78. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Khan MM, Mahmud S, Karim MS, Zaman M and Prince M (2008) Case–control study of suicide in Karachi, Pakistan. British Journal of Psychiatry 193, 402–405. [DOI] [PubMed] [Google Scholar]
  29. Knipe DW, Carroll R, Thomas KH, et al. (2015) Association of socio-economic position and suicide/attempted suicide in low and middle-income countries in South and South-East Asia – a systematic review. BMC Public Health 15, 1055. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Knipe D, Williams AJ, Hannam-Swain S, Upton S, Brown K, Bandara P, et al. (2019) Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: a systematic review and meta-analysis. PLoS Medicine 16, e1002905. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Kosaraju SK, Vadlamani LN, Bashir MS, Kalasapati LK, Rao GC and Rao GP (2015) Risk factors for suicidal attempts among lower socioeconomic rural population of Telangana region. Indian Journal of Psychological Medicine 37, 30–35. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Krishna M, Rajendra R, Majgi SM, Heggere N, Parimoo S, Robinson C and Poole R (2014) Severity of suicidal intent, method and behaviour antecedent to an act of self-harm: a cross-sectional study of survivors of self-harm referred to a tertiary hospital in Mysore, South India. Asian Journal of Psychiatry 12, 134–139. [DOI] [PubMed] [Google Scholar]
  33. Kumar CS, Mohan R, Ranjith G and Chandrasekaran R (2006) Gender differences in medically serious suicide attempts: a study from South India. Psychiatry Research 144, 79–86. [DOI] [PubMed] [Google Scholar]
  34. Kumar S, Verma AK, Singh US and Singh R (2015a) Autopsy audit of intentional burns inflicted by self or by others in North India-5 year snapshot. Journal of Forensic and Legal Medicine 35, 29–32. [DOI] [PubMed] [Google Scholar]
  35. Kumar PNS, Anish PK and George B (2015b) Risk factors for suicide in elderly in comparison to younger age groups. Indian Journal of Psychiatry 57, 249–254. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Malakouti SK, Nojomi M, Poshtmashadi M, Hakim Shooshtari M, MansouriMoghadam F, Rahimi-Movaghar A, Afghah S, Bolhari J and Bazargan-Hejazi S (2015) Integrating a suicide prevention program into the primary health care network: a field trial study in Iran. BioMed Research International 2015, 193729. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Manoranjitham SD, Rajkumar AP, Thangadurai P, Prasad J, Jayakaran R and Jacob KS (2010) Risk factors for suicide in rural south India. The British Journal of Psychiatry 196, 26–30. [DOI] [PubMed] [Google Scholar]
  38. Milner A, Sveticic J and De Leo D (2013) Suicide in the absence of mental disorder? A review of psychological autopsy studies across countries. The International Journal of Social Psychiatry 59, 545–554. [DOI] [PubMed] [Google Scholar]
  39. Motohashi Y, Kaneko Y, Sasaki H and Yamaji M (2007) A decrease in suicide rates in Japanese rural towns after community-based intervention by the health promotion approach. Suicide and Life-Threatening Behavior 37, 593–599. [DOI] [PubMed] [Google Scholar]
  40. Narayanan KK, Duraiappa M and Madathil PT (2020) Psycho social factors in adolescent suicides: a psychological autopsy based study. Indian Journal of Forensic Medicine & Toxicology 14, 402–406. [Google Scholar]
  41. Naveed S, Waqas A, Chaudhary AMD, et al. (2020) Prevalence of common mental disorders in South Asia: a systematic review and meta-regression analysis. Frontiers in Psychiatry 11, 573150. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Parkar SR, Dawani V and Weiss MG (2006) Clinical diagnostic and sociocultural dimensions of deliberate self-harm in Mumbai, India. Suicide and Life-Threatening Behavior 36, 223–238. [DOI] [PubMed] [Google Scholar]
  43. Rajapakse T, Griffiths KM, Christensen H and Cotton S (2014) A comparison of non-fatal self-poisoning among males and females, in Sri Lanka. BMC Psychiatry 14, 1–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Ramdurg S, Goyal S, Goyal P, Sagar R and Sharan P (2011) Sociodemographic profile, clinical factors, and mode of attempt in suicide attempters in consultation-liaison psychiatry in a tertiary care center. Industrial Psychiatry Journal 20, 11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Rao KN, Kulkarni RR and Begum S (2013) Comorbidity of psychiatric and personality disorders in first suicide attempters. Indian Journal of Psychological Medicine 35, 75–79. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Reuben J, Kannapiran RT, Ambujam G, Ghill R and Sakthi M (2020) Psychiatric comorbidity among suicide attempters. European Journal of Molecular & Clinical Medicine 7, 444–467. [Google Scholar]
  47. Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen S and Mata DA (2016) Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA 316, 2214–2236. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Sahoo MK, Biswas H and Agarwal SK (2016) Risk factors of suicide among patients admitted with suicide attempt in Tata Main Hospital, Jamshedpur. Indian Journal of Public Health 60, 260–267. [DOI] [PubMed] [Google Scholar]
  49. Samaraweera S, Sumathipala A, Siribaddana S, Sivayogan S and Bhugra D (2008) Completed suicide among Sinhalese in Sri Lanka: a psychological autopsy study. Suicide and Life-Threatening Behavior 38, 221–228. [DOI] [PubMed] [Google Scholar]
  50. Sandeep S, Sarthak J, Kumar BR and Jayanthi Y (2017) Psychological autopsy of complete suicide cases in Bhopal region of central India: a retrospective study. Medico-Legal Update 17, 12–16. [Google Scholar]
  51. Srivastava A (2013) Psychological attributes and socio-demographic profile of hundred completed suicide victims in the state of Goa, India. Indian Journal of Psychiatry 55, 268–272. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Syed EU and Khan MM (2008) Pattern of deliberate self-harm in young people in Karachi, Pakistan. Crisis 29, 159–163. [DOI] [PubMed] [Google Scholar]
  53. Tahir MN, Akbar AH, Naseer R, Khan QO, Khan F and Yaqub I (2013) Suicide and attempted suicide trends in Mianwali, Pakistan: social perspective. Eastern Mediterranean Health Journal 19, S111. [PubMed] [Google Scholar]
  54. Tanna JA, Patel PN and Kalele SD (2013) Psychological autopsy of suicide cases in Bhavnagar Region of Gujarat, India. Medico-Legal Update 13, 27. [Google Scholar]
  55. Vishnuvardhan G and Saddichha S (2012) Psychiatric comorbidity and gender differences among suicide attempters in Bangalore, India. General Hospital Psychiatry 34, 410–414. [DOI] [PubMed] [Google Scholar]
  56. World Health Organization (2014) Preventing Suicide: A Global Imperative. Geneva, Switzerland: World Health Organization; [Online]. Available at https://apps.who.int/iris/handle/10665/131056 (Accessed 14 June 2021). [Google Scholar]
  57. World Health Organization (2021) Suicide Worldwide in 2019: Global Health Estimates. Geneva, Switzerland: World Health Organization. Available at https://www.who.int/publications/i/item/9789240026643 (Last Accessed 15 September 2021. [Google Scholar]
  58. Yadiyal MB and Aruna G (2011) Psychopathology among suicide attempters: a cross-sectional study. Indian Journal of Forensic Medicine & Toxicology 5, 5–8. [Google Scholar]
  59. Zalsman G, Hawton K, Wasserman D, et al. (2016) Suicide prevention strategies revisited: 10-year systematic review. The Lancet. Psychiatry 3, 646–659. [DOI] [PubMed] [Google Scholar]

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Supplementary Materials

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Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author.

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