Take a Closer Look: Suicide in Low- and Middle-Income Countries (LMICs)

Ellen-ge Denton, PsyD, College of Staten Island, City University of New York

(originally published 10/1/2019)

Sometimes the solution to big problems and questions can be found in much smaller contexts or every day occurrences. 

·      How to begin to get out of debt?... Take lunch to work. 

·      How to get our kids to listen?.... Establish and trust a daily home routine. 

·      How to lose weight?.... Get a health app ☺

In this blog post, I will delve into what is often overlooked about youth suicide risk. I will pitch the gain or benefit to studying youth suicide risk in developing nations. 

Each year, approximately 800,000 people die by suicide worldwide, with suicide reported as the second leading cause of death among 15- to 29-year-olds globally. Analysis of annual suicide mortality data indicate that the greatest proportion of suicides occur in low-to-middle-income countries (LMIC’s). Despite estimates that suicides from LMIC’s contribute to 79% of the worldwide suicide rate, the existing knowledge on suicide is derived primarily from data in high-income countries, with only 10% of all published research on suicides coming from LMIC’s. In a letter to the editor, published in World Psychiatry, Castroman & Lopez inquire, “Are we studying the right populations to understand suicide?” The letter notes that the scientific study of suicide is disproportionately clustered in high income countries, where suicide is a low base rate problem relative to LMIC’s. The authors recommend suicide research with collaborative expertise and consensual definitions between high- and low-income nations. 

So, what would be the purpose of conducting research in LMIC’s? Wouldn’t the high suicide rate in those nations be their problem to solve? Well…

First, more studies with representative samples will lead to more generalizable models of suicide prevention. 

Second, suicidal behavior is complex, and we see that when we consider the extreme variability of contributing risk factors on suicide-related outcomes (e.g., gender, heritability, rural environments, individual psychopathology, etc.). Therefore, studying suicide among diverse populations means greater breadth and representation of the factors that sustain and escalate suicide risk. 

Third, although suicide is preventable, the rising rates indicate that there is a lot that we still do not know. Observing suicide patterns that exist in lesser resourced contexts, such as LMIC’s, rural health, and other populations with little to no mental health capacity, can fill the gaps of what we still have yet to learn regarding risks for suicide.

One big question requiring suicide research effort is how to prevent youth suicide. Research from LMIC’s provides some insight and potential answers to this question. For example, there are consistent reports that suicide attempts are more prevalent than suicide ideation among LMIC populations (Hagaman, 2013; Wasserman et al., 2008; Bertolote, 2010). This suggests a need for improving the assessment of suicide ideation, planning, and attempts. Limited ability to express or communicate frequent or consistent thoughts of self-harm, in LMIC’s, could contribute to this finding. Further, those who work with high-risk populations and/or assess for suicide risk are challenged to refine suicide inquiry and probing to fine-tune assessment of fluctuating risk, as youth may be more apt to attempt suicide rather than find words to articulate suicidal thoughts. The above examples point to important social contexts for available coping resources, problem-solving skills, impulse-control, and/or verbal interactions that can potentially mitigate suicidal behaviors. 

In Guyana, an LMIC in South America, the suicide rate is 29.2 per 100,000 people, with rates higher among males than females. However, female youth in Guyana had the highest worldwide rates of suicide among 15-19-year-olds in 2000-2009. Guyanese youth interviewed about factors that might be protective against suicide revealed a desire for validating, non-judgmental, active listening, and non-dismissive communication with adults and peers (Arora et al., in press). Furthermore, in a psychological autopsy study in rural South India, 60% of suicides did not have a mental illness before death. Instead, severe distress related to conflict, impulsivity, social and economic strain, and no alternative means of coping precipitated the suicide deaths. Closer investigation of interpersonal variables (or lack thereof), in LMIC settings, may shed some light on ways to prevent youth suicide in these settings. 

While we are still in search of solutions to suicide deaths, the wake it leaves behind, and risks associated with suicide attempts and exposure, we can broadly consider that investigating youth with higher suicide risk prevalence will help identify solutions. When it comes to preventing youth suicide, Sukant Ratnakar might have said it best: “observation opens the windows of knowledge around us.”  

References

1.     Hagaman, A.K., Wagenaar, B.H., McLean, K.E., Kaiser, B.N., Winskell, K., & Kohrt, B.A. (2013). Suicide in rural Haiti: clinical and community perceptions of prevalence, etiology, and prevention. Social Science & Medicine, 83, 61-69. 

2.     Wasserman, D., Thanh, T. T., Minh, P. T., Goldstein, M., Nordenskiöld, A., & Wasserman, C. (2008). Suicidal process, suicidal communication and psychosocial situation of young suicide attempters in a rural Vietnamese community. World Psychiatry, 7, 47-53. 

3.     Bertolote, J.M., Fleischmann, A., De Leo, D., Phillips, M.R., Botega, N.J., Vijayakumar, L., De Silva, D., Schlebusch, L., Nguyen, V.T., Sisask, M., Bolhari, J., & Wasserman, D. (2010). Repetition of suicide attempts: data from emergency care settings in five culturally different low- and middle-income countries participating in the WHO SUPRE-MISS Study. Crisis, 31, 194-201.

4.     Manoranjitham, S., Jayakaran, R., & Jacob, K. (2007). Perceptions about suicide: A qualitative study from southern India. The National Medical Journal of India, 48, 72.

5.     Manoranjitham, S. D., Rajkumar, A. P., Thangadurai, P., Prasad, J., Jayakaran, R., & Jacob, K.S. (2010). Risk factors for suicide in rural south India. British Journal of

Psychiatry, 196, 26-30.

6.     Kõlves, K., & De Leo, D. (2016). Adolescent suicide rates between 1990 and 2009: Analysis of age group 15–19 years worldwide. Journal of Adolescent Health, 58, 69-77.

7.     Arora, P., Persaud, S., & Parr, K. (in press). Risk and protective factors for suicide among Guyanese youth: Youth and stakeholder perspectives. International Journal of Psychology.https://onlinelibrary.wiley.com/journal/1464066X