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Suicide by poisoning in Pakistan: review of regional trends, toxicity and management of commonly used agents in the past three decades

Published online by Cambridge University Press:  17 June 2021

Maria Safdar*
Department of Forensic Medicine, Postgraduate Medical Institute, Pakistan
Khalid Imran Afzal
Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Illinois, USA
Zoe Smith
Department of Psychology, Loyola University, Illinois, USA
Filza Ali
Department of Forensic Medicine, CMH Multan Institute of Medical Sciences, Pakistan
Pervaiz Zarif
Department of Forensic Medicine, Postgraduate Medical Institute, Pakistan
Zahid Farooq Baig
Department of Medicine, CMH Lahore Medical College and Institute of Dentistry, Pakistan
Correspondence: Maria Safdar. Email:
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Suicide is one of the leading mental health crises and takes one life every 40 seconds. Four out of every five suicides occur in low- and middle-income countries. Despite religion being a protective factor against suicide, the estimated number of suicides is rapidly increasing in Pakistan.


Our review focuses on the trends of suicide and means of self-poisoning in the past three decades, and the management of commonly used poisons.


We searched two electronic databases (PubMed and PakMediNet) for published English-language studies describing agents used for suicide in different regions of Pakistan. A total of 46 out of 85 papers (N = 54 747 cases) met our inclusion criteria.


Suicidal behaviour was more common among individuals younger than 30 years. Females comprised 60% of those who attempted suicide in our study sample, although the ratio of completed suicides favoured males. There were regional trends in the choice of agent for overdose. Organophosphate poisoning was reported across the nation, with a predominance of cases from the agricultural belt of South Punjab and interior Sindh. Aluminium phosphide (‘wheat pills’) was a preferred agent in North Punjab, whereas paraphenylenediamine (‘kala pathar’) was implicated in deaths by suicide from South Punjab. Urban areas had other means for suicide, including household chemicals, benzodiazepines, kerosene oil and rat poison.


Urgent steps are needed, including psychoeducational campaigns on mental health and suicide, staff training, medical resources for prompt treatment of self-poisoning and updated governmental policy to regulate pesticide sales.

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Copyright © The Author(s), 2021. Published by Cambridge University Press on behalf of the Royal College of Psychiatrists

Suicide is the second leading cause of death in 15- to 29-year-olds globally, and 10- to 34-year-olds in the USA.1,2 The World Health Organization (WHO) estimates that 800 000 people die by suicide every year, which translates into one death every 40 seconds, and 79% of global suicides occur in low- and middle-income countries (LMICs).3 The World Bank Atlas defines low-income countries as having a gross national income (GNI) per capita of $1025 or less in 2018, and lower-middle-income countries as having a GNI per capita of $1026–$3995.Reference Prydz and Wadhwa4 Although pesticide ingestion, hanging and firearms are among the most common methods of suicide worldwide,1 trends vary between nations regarding the age groups, access and availability of the means.Reference Cha, Chang, Choi and Lee5Reference Snowdon8 Mirroring global studies, the three most common methods for suicides in Pakistan are poisoning, firearms and hanging.Reference Abdullah, Khalily, Ahmad and Hallahan9,Reference Shekhani, Perveen, Hashmi, Akbar, Bachani and Khan10


Pakistan is the fifth most populous country in the world.11 It is predominantly an agricultural country and, according to the 2017 National Census, around 64% of its population of 207 million is considered rural.12,Reference Rehman, Jingdong, Shahzad, Chandio, Hussain and Nabi13 The population ratio favours males (51.23%), with a male:female ratio of 1.05.12 About 50% of the population is under 20 years of age, and 35% is under 15 years of age. The literacy rate of Pakistan, as measured by the ability of people aged ≥15 years to read and write, is around 59%, which is lower than the average literacy rate in other South Asian countries (71.70%) and for LMICs overall (75%).14 Men have a literacy rate of 71%, whereas women have a literacy rate of <47%.12,14,Reference Hunter15 The literacy rate in large urban centres such as Karachi and Lahore, the two largest cities in the country, is close to 75%, whereas the average literacy rate in rural areas is <50%.Reference Rehman, Jingdong and Hussain16 Along with other factors, terrorism has negatively affected sustained economic growth in Pakistan over the past two decades, leading to a high unemployment rate. The health indicators of the country continue to remain poor.Reference Zakaria, Jun and Ahmed17Reference Shah20

Geography and demography

Geographically, the country is composed of four provinces – Punjab, Sindh, Balochistan, and Khyber Pakhtunkhwa (KPK) – and Gilgit–Baltistan, a newly created province in the north (Fig. 1).Reference Anjum, Saeed Ali, Akber Pradhan, Khan and Karmaliani21,Reference Rej22 The Punjab and Sindh are fertile plains with agriculture-based economies. Balochistan and KPK are bound by strong tribal traditions. Gun ownership is a shared pride between the two provinces. Balochistan is rugged, rich in minerals and mostly barren.23,Reference Finlayson24 In the north of Pakistan, Gilgit–Baltistan is home to three large mountainous ranges: the Himalayas, the Karakoram and the Hindu Kush. The scenic region has beautiful valleys and river-irrigated lands.Reference Anjum, Saeed Ali, Akber Pradhan, Khan and Karmaliani21,Reference Bukhari25 Shah and AmjadReference Shah and Amjad26 measured the cultural diversity of different regions of Pakistan. They found a high masculinity index score in all provinces, indicating a difference in social genders, with clear-cut roles. Uncertainty avoidance index scores were low in all provinces, mainly because a firm belief in Allah (God Almighty) led to most people not feeling threats or uncertainty about the future. Individualism index scores were low in all provinces, especially in KPK and Balochistan, signifying collectivism as a national culture. The people of Pakistan possessed a strong urge toward group cohesiveness and the expectation of loyalty.Reference Shah and Amjad26

Fig. 1 Geographical map of Pakistan. AJK, Azad Jammu and Kashmir; KPK, Khyber Pakhtunkhwa.

Approximately 96% of the population of Pakistan is Muslim.27,Reference Hussain28 Like other major religions, Islam condemns suicide, declaring it an unforgivable sin.Reference Gearing and Lizardi29Reference Chaleby31 This could be a significant deterrent to suicide, evidenced by the traditionally low rates reported in Muslim countries compared with non-Muslim countries.Reference Simpson and Conklin32 Based on religious tenets, both suicide and self-harm are illegal and punishable by imprisonment and fines under Pakistani law, adding another deterrent to suicide.Reference Faruqui and Afghan33Reference Lester35 Studies from other LMICs and higher-income (GNI per capita of ≥$12 376) Muslim-majority countries also show a lower suicide rate than non-Muslim-majority countries.Reference Eskin, AlBuhairan, Rezaeian, Abdel-Khalek, Harlak and El-Nayal36,Reference Karamouzian and Rostami37 Arya et al describe the geographical heterogeneity of suicide rates in the neighbouring LMIC of India, focusing on religion, caste, tribe, etc. The authors found that the rate of suicide was lowest for Sikhs and Muslims, and highest for Hindus and Christians.Reference Arya, Page, Dandona, Vijayakumar, Mayer and Armstrong38

Suicide statistics

Pakistan has no vital registrations and lacks accurate figures for death by suicide.Reference Pritchard, Iqbal and Dray39 As compared with the 2017 global suicide death rate per 100 000 people for both genders of 9.98,40 the estimated age-standardised suicide rate in Pakistan is 4.4 per 100 000 people.Reference Bachmann41 The suicide death rates in neighbouring India, Bangladesh and Sri Lanka are 13.33, 5.73 and 7.55 per 100 000 people, respectively. Despite the low estimated rate, recent data suggest that suicide is becoming a significant public health problem in Pakistan.Reference Khan, Mahmud, Karim, Zaman and Prince42Reference Anjum, Saeed Ali, Akber Pradhan, Khan and Karmaliani45 The WHO published a report showing an increase in the reported suicide rate of 2.6% from the year 2000.1 Because of the social, legal and religious factors noted above, suicide and self-harm are not reported or are underreported. Recent reports have shown rapidly increasing rates for suicide and self-harm across the country.Reference Khan and Hyder34,Reference Khan, Mahmud, Karim, Zaman and Prince42,Reference Hassan46 Shekhani et al noted a stigmatisation of suicidal behaviour contributing toward a lack of research on the subject.Reference Shekhani, Perveen, Hashmi, Akbar, Bachani and Khan10 We did not find literature on suicide or self-harm that compared different regions of Pakistan or differentiated between urban and rural populations.

To address the gap in current knowledge, this is the first study to map the regional trends of suicide by poisoning in Pakistan, and detail urban versus rural differences. We also aim to provide a detailed account of the pathophysiology and management strategies of agents used in suicide attempts, to give readers a comprehensive review on the subject. Our analysis will provide future research directions and inform policy for suicide prevention in Pakistan, focusing on regional and urban versus rural differences in suicide attempts.


We searched two electronic databases (PubMed and PakMediNet) for studies describing agents used for suicide in different regions of Pakistan, using the following terms: suicide, death, poisoning, drugs, overdose and Pakistan. We considered studies published in the English language within the past 30 years, and conducted the search from October to December 2019. Our null hypothesis was that there is no regional or urban versus rural difference in suicide by poisoning in Pakistan. We included primary research, case series and case reports, focusing on different agents used by adults of both genders, aged ≥18 years, who attempted suicide. Studies involving ex-pat Pakistanis and those using means of suicide other than overdose were excluded. We did not include single case reports as most focused on uncommon means of death or unusual clinical presentations that were not the focus of our study. The Postgraduate Medical Institute at Lahore, Pakistan, approved all of the data collection for this research project according to its policies regarding studies involving human patients.

After retrieving 85 articles from both databases, two independent reviewers screened the titles and abstracts for relevance. Sixty-two papers met the inclusion criteria; however, sixteen were case reports and were not included. Most studies were descriptive, with only three that used a case–control design. The majority of the studies were from urban areas (74%) and addressed determinants rather than risk factors. The WHO defines determinants as a range of behavioural, biological and socioeconomic factors that influence the health of populations.47 The risk factors are characteristics or attributes within an individual that influence the likelihood of disease.Reference Shekhani, Perveen, Hashmi, Akbar, Bachani and Khan10 Most studies reported gender (95.3%) and age (93.0%) differences. We identified eight distinctive regions, including North and South Punjab, North and South KPK, interior Sindh (all cities except Karachi), urban Sindh (represented by studies from the largest city of Karachi), Balochistan and Gilgit–Baltistan (Table 1). The four predominant agents used in the attempted and completed suicides were organophosphates, aluminium phosphide (or ‘wheat pills’), paraphenylenediamine (or ‘kala pathar’) and others (including over-the-counter medications and household chemicals). We describe the clinical presentation, pathophysiological mechanism, morbidity, mortality and available treatments in the Discussion section. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Table 1 Studies on commonly used agents for poisoning in Pakistan, by region

KPK, Khyber Pakhtunkhwa; NSAID, non-steroidal anti-inflammatory drug.

a. Studies cited more than once because of multiple toxins/drugs involved.


Table 1 shows the distribution of studies according to the regions, with details on study design, cohort size, gender, mean age, geographical region, city, suicide attempts or completion methods, and mortality. The exact doses of agents used in the suicide attempts were inconsistently reported and were not statistically meaningful for our study. The majority of the studies were from urban areas (74%) and addressed determinants rather than risk factors. Most studies reported the gender (95.3%) and age (93.0%) of the individuals. We identified eight distinctive regions, including North and South Punjab, North and South KPK, interior Sindh (all cities except Karachi) and urban Sindh (represented by studies from the largest city Karachi), Balochistan and Gilgit–Baltistan (Table 1). The four predominant agents used in the attempted and completed suicides were organophosphates, aluminium phosphide, paraphenylenediamine and others (including over-the-counter medications and household chemicals). Of the 47 studies, 53.2% examined organophosphates (n = 25), 36.2% examined over-the-counter agents and household chemicals (n = 17), 23.4% examined kala pathar (n = 11), 19.1% examined wheat pills (n = 9) and 4.3% examined ‘intoxication’ without indicating the agent used (n = 2). Note that some studies examined multiple agents, so the total exceeds the number of studies included. With the exception of two studies, all papers were published in the past two decades.

The total number of cases across the 53 studies was 54 747 (see Table 2). A total of 60% of overall study participants were female and 40% were male. Suicidal behaviour was more common among individuals aged <30 years, with a mean age of 27.9 years. See Table 3 for more comprehensive demographic information. Urban Sindh had the most publications (14 studies; n = 25 458), followed by North Punjab (12 studies; n = 2319), South Punjab (7 studies; n = 1901), interior Sindh (6 studies; n = 1027), North KPK (4 studies; n = 438), South KPK (2 studies; n = 541) and one study each from Balochistan (n = 46) and Gilgit–Baltistan (n = 46) (see Table 4 for demographic information by region). The overall mortality rate, regardless of the method, was 24.5%. Organophosphates were the most widely reported agent (25 studies; n = 35 479), with an average mortality rate of 13.9% (11 studies; n = 2364). The highest average mortality rate was for wheat pills, at 44.7% (9 studies; n = 2070). The lowest average mortality rate was for over-the-counter agents and household chemicals (17 studies; n = 20 911), at 12.1%. For kala pathar, the average mortality rate was 38.6% (11 studies; n = 2364). See Table 5 for more demographic information by different agents.

Table 2 Overall demographic information for included studies

Table 3 Demographic information of included studies by region

Table 4 Demographic information of included studies by agent

Table 5 Overview of commonly used poisons in Pakistan

ATN, acute tubular necrosis; KPK, Khyber Pakhtunkhwa; CNS, central nervous system.

Studies from Karachi (i.e. urban Sindh) included 25 458 individuals, of whom 55.1% were women aged 20–43 years (mean age 27.5 years). The average overall mortality rate for this region was 7.46 and ranged from 0 to 42%. Most studies from Karachi (73.3%) found organophosphates as the agent chosen for death by suicide, with an average mortality rate of 9.33 (range 0–20%). Other agents were also examined, including benzodiazepines, off-label agents, pesticides, corrosives, kerosene oil, rat poison, non-steroidal anti-inflammatory drugs (NSAIDs)/analgesics, and antidepressants. Two studies found that 55–91% of 771 people chose benzodiazepines as the agent of choice for attempting suicide. However, benzodiazepine overdose was associated with a 0% mortality rate in these studies. One study found that 18% of 2546 individuals chose off-label agents, whereas another study found that 15% of 705 individuals chose pesticides. Two studies of 3708 individuals found that 13.5% used corrosives. Kerosene oil was examined in two studies, with 2–14% of 15 259 individuals using it to commit suicide. Finally, rat poison (11% of 2546 individuals), NSAIDs/analgesics (11% of 324 individuals) and antidepressants (10% of 324 individuals) were all examined in one paper.

Interior Sindh included six studies from three cities: Hyderabad, Jamshoro and Nawabshah. The latter two cities are rural. There were 1027 individuals aged 16–43 years (mean age 32.5 years), of whom 53.1% were female. The most commonly studied agent was organophosphates (66.6% of studies, 987 individuals), whereas the other two studies examine kala pathar (40 individuals). Mortality rates for organophosphates ranged from 17 to 27% (mean 20.5%), whereas aluminium phosphide (two studies; n = 40) was higher at 38–42% (mean 40%). Overall mortality rates for this region averaged at 27%.

Within North Punjab, a total of 2319 cases were noted in 12 studies, with a male:female gender ratio of 50.5%:49.5% favouring males. The age range was 20–40 years (mean age 26.6 years) across six cities (Kharian, Lahore, Mianwali, Rawalpindi, Sahiwal and Wah Cantt). Of these cities, Mianwali and Sahiwal are considered rural, and the other four are urban. The overall mortality rates range from 2.5 to 87%, with a mean percentage of 43.8%. In North Punjab, almost half of individuals who ingested wheat pills died by suicide, indicating the high lethality of the agent. The overall mortality rate for wheat pills ranged from 33 to 87%, with an average of 52%. Other agents examined in the region included organophosphates (four studies), corrosives (two studies), benzodiazepines (one study), generic agents (one study), medicine (one study), ‘toxic substance’ (one study), pesticides (one study), household toxins (one study), bleach (one study), kala pathar (one study) and rat poison (one study). Mortality rates were not reported for these agents.

There were 1901 cases in 7 studies from three cities in South Punjab (Bahawalpur, Multan and Rahim Yar Khan). This region consisted of all urban cities, although the healthcare facilities’ catchment area extends into vast agricultural lands. Women comprised 68.4% of the samples, with an age range of 21–30 years (mean age 23.4 years). All seven studies examined paraphenylenediamine (kala pathar) poisoning, with a mortality rate of 28% (ranging from 21 to 39%). Only one study examined corrosives as the substance of choice for overdose, but this study did not report mortality.

North KPK included four studies with 438 cases from two cities: Peshawar (urban) and Chitral (rural). Women comprised 57% of the reported cases, with an age range of 26–31 years (mean 28.5 years). Mortality rates ranged from 10 to 44%, with an average overall mortality rate of 21%. No clear choice of agent for overdose emerged; however, similar to urban Sindh, organophosphates were included in three of the four studies, with a prevalence rate of 31–36%. Aluminium phosphide and benzodiazepines were the agents of choice 11% and 13% of the time, respectively. Interestingly, one study included methods outside of poisoning, finding that only 5% of individuals preferred an overdose by agents compared with other methods (drowning 52%, hanging 26%, firearms 17%).

For South KPK, there were two studies, both from Dera Ismail Khan, which is a rural area. There were 541 participants across the two studies, of whom 87% were female, and the average age was 23.8 years (range 12–39 years). Both studies only examined kala pathar, finding a high overall mortality rate of 63.5% (range 47–80%). One study included only 38 participants, 95% of whom were female, with a mortality rate of 47%. The second study confirmed the findings of the first paper, with a much higher number of reported cases (503 cases). The number of men in the second study rose to 21%, and the mortality rate rose to around 80%.

In Balochistan, there was only one study examining agents used by people attempting suicide. This sample included only 46 female participants in Quetta, an urban centre and the largest city in the province. This study only examined organophosphates but did not report mortality rates.

The Gilgit–Baltistan region included only one study, in the city of Ghizer (a rural town). This study included 49 individuals, all of whom were female. The means of suicide included jumping into a body of water (40%), ingesting a poisonous agent (30%), strangulation (11%) and the use of a firearm (5%). Mortality rates were not reported in this study.

In summary, organophosphate poisoning was reported from all four provinces. However, organophosphates played a more substantial role in the cases of suicide reported from North Punjab and interior Sindh, where it accounted for up to 60% of reported cases. Aluminium phosphide (wheat pill) poisoning was noted in agent overdoses reported mainly from North Punjab and North KPK, whereas paraphenylenediamine (kala pathar) was primarily used in suicide from South Punjab, with some reports from South KPK and interior Sindh. Compared with the rural population (where pesticides and paraphenylenediamine were most common), the urban population chose more varied agents for overdose, including household chemicals (bleach, corrosives), medicines (sedatives, tranquilisers, NSAIDs, antidepressants), rat poison pills and other toxic substances. Other means of suicide, such as hanging (asphyxiation), gunshot and drowning, were not the focus of our paper. Some studies in our analysis reported the reason for the suicide attempt. Five themes emerged, including financial problems, family conflicts, illicit spousal relationships, serious medical illness and failed romance. Studies did not report risk factors for suicide consistently enough to allow for a complete analysis of regional or urban versus rural differences in these risk factors.


To our knowledge, this is the first study to focus on the regional difference in suicide by poisoning in Pakistan. The results also suggest urban versus rural differences in the choice of poison. We discuss determinants of suicide behaviour and comprehensive management strategies for commonly used agents, to address existing gaps in suicide literature.

Our study found that pesticides (organophosphates and aluminium phosphide) are the most frequently used agents for suicide across Pakistan. As noted above, agriculture is the backbone of Pakistan's economy. The main crops include cotton, wheat, rice, maize and sugarcane, in addition to a large variety of regional fruits and vegetables.Reference Rehman, Jingdong, Shahzad, Chandio, Hussain and Nabi13,Reference Miller, Yusuf, Chow, Dehghan, Corsi and Lock95 The need to meet the ever-increasing demand is one of the driving forces of the phenomenal rise in pesticide use in farming and agriculture. It does not spare even the remote areas of Pakistan.Reference Mohammad, Mohammad Rasul and Hizbullah96,Reference Ullah, Asghar, Baqar, Mahmood, Ali and Sohail97 Pesticides are regulated in Pakistan by the Agriculture Pesticide Ordinance of 1971 (amended up to 1997) and Agriculture Pesticides Rules of 1973.Reference Ali98 Pakistan's Agriculture and Research Council detailed several elements regarding registration, production, procurement, transportation, distribution, sale, storage, usage and the safe disposition of empty containers.Reference Ali98 There are also institutional arrangements for pesticide monitoring and research.Reference Jabbar and Mallick99 However, pesticides are readily available, and their unrestricted use continues to be widespread.Reference Mughal100 A sobering study from the Khoj Foundation in 2009 reported that Pakistan used 14 times more pesticides for wheat and rice crops than India. Furthermore, the researchers found:

‘Pesticides are often stored in living rooms, among cookware and plates, and the bags in which they are sold are sometimes reused and sewn into quilts or floor covering. Utensils used to mix pesticides are often also used for cooking. They found that because women are not involved in the decision making around pesticide use and work both in the fields and in the home where pesticides are stored, they are at increased risk of poisoning.’101

Corresponding to these findings, several studies have investigated suboptimal or a complete lack of knowledge and awareness of pesticide hazards in these regions.Reference Ahmad, Shahid, Khalid, Zaffar, Naqvi and Pervez102Reference Khan, Mahmood and Damalas104 Although unintentional poisoning is beyond the scope of this paper, this information is crucial in providing a glimpse of the problem and how it relates to easy accessibility and means for self-harm and suicide.

In our analysis, organophosphate overdose was reported in studies from across Pakistan, with the highest number of cases from the Punjab and Sindh regions (Table 5). Twelve studies were from Karachi, representing urban Sindh. We believe that, being the largest city of the province and Pakistan, Karachi receives patients with suicide overdose from all over Sindh, to receive care in its well-equipped medical institutions.105 Thus, the number of organophosphate poisonings from Karachi likely represents rural rather than urban Sindh. Similarly, studies from other metropolitan cities, such as Lahore or Rawalpindi in Punjab, treated patients with poisoning who were transferred from the surrounding rural areas to receive treatments. In the wheat-growing regions of North Punjab, aluminium phosphide or wheat pills are more readily available and were the most common agents to attempt suicide. North KPK also reported a high incidence of aluminium phosphide use.

Interestingly, there was no report of aluminium phosphide overdose from urban or interior Sindh, indicating that availability could be the critical factor in the choice of agent in suicide. As opposed to inhalational or skin contact in unintentional poisoning, ingestion was the most common method for suicide by pesticide.Reference Amir, Raza, Qureshi, Mahesar, Jafferi and Haleem106Reference Boedeker, Watts, Clausing and Marquez109 The chemical structure and management of organophosphates and aluminium phosphide poisoning are discussed later in the paper.

Paraphenylenediamine is an ingredient in a compound commonly known as kala pathar (Black Stone) in Urdu. It is used as a chemical ingredient in temporary tattoo ink, fabrics, dark makeup, photocopying inks, printing, rubber products and gasoline. In the Indian subcontinent and North Africa, paraphenylenediamine is an ingredient of black henna, which is used for hair dye and tattoo ink.Reference Abdelraheem, El-Tigani, Hassan, Ali, Mohamed and Nazik110Reference Ismaeel112 Paraphenylenediamine was noted as the agent of choice for suicide in South Punjab, South KPK and interior Sindh. Its easy availability, unrestricted sale as a hair dye and the associated low cost of 10 PKR for a single dose (1 USD = 160.36 PKR (at the time of publication)) are the likely reasons behind the increasing number of cases in recent years.Reference Birmani113 The ease of preparing the suicide concoction by mixing kala pathar in water increases the probability of its use in poisoning.Reference Ahmed114 Following the increasing number of cases, a unified social and print media campaign against the rapidly rising number of suicides with kala pathar led Punjab's government to issue a temporary ban on its open trading in September 2017 in South Punjab. In April 2018, the Punjab government expanded the temporary ban on kala pathar throughout the whole province.Reference Ahmed114Reference Goldsmith, Pellmar, Kleinman and Bunney116 The management of paraphenylenediamine poisoning is discussed later.

We found significant differences in the choice of agents for suicide in urban versus rural populations (see Table 4). Kala pathar was used in 36% of overdose cases in the urban areas as opposed to 64% from the rural regions. More than 85% of the poisoning cases choosing organophosphates, aluminium phosphide and miscellaneous agents were from rural areas, whereas 94% of over-the-counter poisoning cases were from urban areas. Over-the-counter agents included drugs/medicines (benzodiazepines, tranquilisers, NSAIDs/analgesics, antidepressants, etc.), household toxins (bleach, rat poison pills or rodenticides, insecticides) and kerosene oil. The availability, accessibility and ease of use appeared to be significant factors influencing the choice of agents for suicide in our study.

Interestingly, the gender distribution was relatively similar for all agents except kala pathar, which favoured females (74% female v. 25% male). The category of ‘miscellaneous agents’ was mostly reported in males (19% female v. 81% male). Drowning or jumping into a lake or a river was a preferred method for suicide in North KPK and Gilgit–Baltistan, where there is ready access to rivers, lakes and streams. Except for North Punjab, where the female:male suicide ratio is almost equal, all other reported regions showed a higher incidence of reported suicide in females compared with males (see Table 3). The average age of suicide in our data was 27.9 years, with the youngest reported age of 20.5 years in Balochistan.

Suicide is a complex phenomenon, and its identity is often shrouded in mystery. Unspoken religious and cultural factors, especially in LMICs, may contribute toward its inadequate understanding, and Pakistan is no exception.Reference Goldsmith, Pellmar, Kleinman and Bunney116 Our study highlights social determinants such as financial problems, gender and cultural stressors influencing suicide. Although not reported in all of the studies, we identified economic issues, family conflicts, illicit spousal relationships, serious illness and failed romance as commonly identified reasons for suicide. Pakistan is an economically strained country with a high unemployment rate.19 Previous reports from the region similarly found a range of socially and culturally specific family problems, typically involving spouses, in-laws, parent–child conflicts, unfulfilled expectations at work or failure in school, and mental turmoil to be factors in suicide attempts.Reference Goldsmith, Pellmar, Kleinman and Bunney116 Pakistan's regional differences influence the execution of cultural norms. As discussed earlier, a low individualism index promotes collective culture, and a high masculinity index defines boundaries and gender roles.Reference Shah and Amjad26 A deviation from tribal tradition could lead to a sense of betrayal among other clan members that can incite violence, especially against women.Reference Shekhani, Perveen, Hashmi, Akbar, Bachani and Khan10 We found that all reported cases of suicide from Balochistan and Gilgit–Baltistan were females. In a recent news report, female suicides in the region were associated with the lack of freedom in choosing potential husbands.Reference Shah117

Ali et al suggest domestic and social issues as the most common reason for overdose accounting for up to 70% of the cases.Reference Ali, Abbasi, Ahmad, Fazal, Khan and Ali118 In comparison, prior psychiatric history of suicide was possibly linked with suicide attempts in only 10% of the patients.Reference Rahim, Ullah, Haroon, Ashfaq and Afridi54 As opposed to high-income countries, where primary psychiatric disorders such as major depression are often reported to be present in 80%–90% of deaths by suicide, in Pakistan, a premorbid mental health diagnosis is often absent.Reference Knipe, Williams, Hannam-Swain, Upton, Brown and Bandara119 Treatment could potentially be delayed, as the patient's history, although very important, is often unreliable in suicide attempts.Reference Hom, Stanley, Duffy, Rogers, Hanson and Gutierrez120,Reference Hom, Joiner and Bernert121 Fear of persecution, stigma and confidentiality around such a sensitive issue may lead to the concealment of facts, both by the patient and the family.Reference Naveed, Qadir, Afzaal and Waqas122

Gender inequality and discrimination are significant issues both globally and in Pakistan.Reference Hausmann, Tyson and Zahidi123 The country has a deep-rooted patriarchal culture with unequal gender role expectations.Reference Chauhan and Chauhan124Reference Georgas, Berry, Van de Vijver, Kağitçibaşi and Poortinga126 Women are expected to do household chores for the extended family. Men are the primary authority figures and considered the traditional breadwinners, which gives them a superior position to women. Although an increasing number of women are economically active, both in rural and urban areas, society has yet to recognise their contribution.23 Women are seldom included in decision-making and continue to be victims of abuse.Reference Ali, Krantz, Gul, Asad, Johansson and Mogren125,Reference Rabbani, Qureshi and Rizvi127 Lack of gender-sensitive policies seems to hinder equitable political and economic status, birth gender ratios, illiteracy rates, maternal mortality rates and other health indicators in South Asian women.Reference Gill and Stewart128 As opposed to the West, marriage does not seem to be a protective factor against suicide in Pakistan. This likely indicates the high level of marital stress married women face compared with single women.Reference Shahid, Iqbal, Khan, Khan, Shamsi and Nakeer129 Ali et al identified the pursuit of higher education as an agent toward change for all genders in Pakistan. The authors also recognised the role of mass media in supporting women's empowerment.Reference Ali, Krantz, Gul, Asad, Johansson and Mogren125

With the increasing availability of handheld devices and internet access in both urban and rural areas of Pakistan, the influence of social media on suicide behaviour cannot be disregarded. In a recent study, Cheng et al identified the role of social media and Facebook in depicting suicide and having an intended effect of similar choice of agent in other suicides.Reference Cheng, Chen and Yip130,Reference Ruder, Hatch, Ampanozi, Thali and Fischer131 Others have focused on local newspapers and the impact of reporting suicide on the front pages.Reference Sun, Lu, Tseng and Chiang132

Religious beliefs can provide a series of effective coping strategies (e.g. prayer, rituals, religious services and social networks) that are considered as protective factors against suicide.Reference Gearing and Alonzo133 A strong belief in God and that whatever happens is by Allah's will may create an atmosphere of acceptance rather than desperation in Muslims.Reference Shah and Amjad26 Rezaeian argues that Islam attempts to address the underlying factors contributing to the suicidal state, such as promoting mental health by the remembrance of the creator (Zikr), decreasing poverty by the distribution of wealth through mandatory charity (Zakat), and forbidding alcohol and other intoxicants.Reference Rezaeian134 Although religious beliefs and laws against suicide may be a deterrent, inadvertent negative consequences, such as a delay in help-seeking, fear of prosecution by the police and legal authorities, stigma and a lack of reliable statistics, can also occur.Reference Khan and Mian30 For religious families, suicide is viewed as a sin and a failure rather than an illness. It may dictate family reactions, treatment-seeking behaviours, explanations of disease and adherence to treatment.Reference Pritchard, Iqbal and Dray39 It is important to note that the clinicians’ own religious view of suicidal behaviour may lead to unconscious biases in delivering clinical care, and could lead to moral and ethical dilemmas when treating such patients.Reference Khan and Mian30

Recent literature has challenged the notion of outright faith-based protection. Pritchard et al explored ‘hidden’ or missed suicides in Islamic countries. They suggested that the official records seemed to be at odds with the study results purporting a higher number of suicides in Muslim-majority countries than previously reported.Reference Pritchard, Iqbal and Dray39,Reference Pritchard and Amanullah135 The authors identified the risk of the unrecognised or denied extent of suicidal behaviour, undermining the necessary steps to support the individual and prevent fatal outcomes. Similarly, Jordans et al found a higher reported suicide rate in South Asia, mainly driven by Bangladesh (a Muslim-majority country), India and Sri Lanka, compared with the global average.Reference Jordans, Kaufman, Brenman, Adhikari, Luitel and Tol136

Our data did not report on individual risk factors for suicide. However, we include a brief overview to emphasise its importance in the study of suicide. Previous analyses showed poor impulse control, premorbid depression, a history of physical/sexual or emotional abuse, high risk-taking behaviour and low self-esteem as contributing toward self-harm and suicide.Reference Bachmann41 Cognitive factors such as low IQ and limited education; poor problem-solving or inadequate communication skills; lack of distress tolerance; and the timing of the attempt, such as after a similar attempt in the family or neighbourhood, may also have a significant effect on the choice of agent in self-poisoning.19,Reference Khezeli, Hazavehei, Ariapooran, Ahmadi, Soltanian and Rezapur-Shahkolai137,Reference Cole, Littlefield, Gauthier and Bagge138 Copycat suicides or Werther's syndrome have long been identified as drivers of cluster suicides.Reference Celik, Kalenderoglu, Almis and Turgut139Reference Mirza and Jenkins143 Although we did not look for the timing of cluster suicides in our analysis, it should be explored in future studies.Reference Birmani113 In short, the prevalence, characteristics and methods of suicidal behaviour vary widely between different communities, across other demographic groups and over time.Reference Hansen, Braslow and Rohrbaugh144

Structural determinants of health account for some of the regional variations noted in our study.Reference Metzl and Hansen145,Reference Kirmani146 We argue that the easy and unrestricted availability of drugs/medicines could be one reason for these regional variations. Ali et al have raised concern about the lack of regulation for over-the-counter drugs in Pakistan, leading to misuse and overuse.Reference Ali, Abbasi, Ahmad, Fazal, Khan and Ali118 The authors did not consider the risk of suicide overdose with uncontrolled access to medications, which we believe should be factored into future regulations. Pakistan's growing income inequality and increase in poverty are concerning.Reference Kirmani146,Reference Shams and Kadow147 Li and Katikireddi emphasised the urban–rural inequalities as a driver of suicide trends.Reference Li and Katikireddi148 The efforts to decriminalise suicide in Pakistan gained momentum likely after India decriminalised suicide in 2015.Reference Shekhani, Perveen, Hashmi, Akbar, Bachani and Khan10,Reference Varshney, Gupta and Balhara149,Reference Majeed, Amir Sherazi and Afzal150 Although Islam condemns those who commit suicide, no legal or societal punishment is mentioned for suicide survivors in the Quran.Reference Naveed, Qadir, Afzaal and Waqas122 In February of 2018, the Pakistan Senate passed a bill for treatment of those who attempt suicide and survive, rather than punishment under Section 325 of the Pakistan Penal Code.Reference Our151

With the alarming rise of suicide rates in Pakistan, we must emphasise urgent steps to halt and gradually reverse the suicide trends. It is imperative to initiate mental health literacy and psychoeducational campaigns in vulnerable communities, to identify high-risk individuals and the hazardous effects of agricultural chemicals.Reference Munawar, Abdul Khaiyom, Bokharey, Park and Choudhry152 Furthermore, increasing the availability of resources for timely and prompt treatment of overdose may prevent dire consequences. The role of partnership with local leaders and utilisation of existing resources in such endeavours, such as governmental or non-governmental organisations, especially in rural areas, cannot be overemphasised.Reference Cha, Chang, Gunnell, Eddleston, Khang and Lee153,Reference Gunnell, Fernando, Hewagama, Priyangika, Konradsen and Eddleston154 In a recent article, Eddleston and Gunnell focused on preventing suicide through regulating pesticides, especially in LMICs.Reference Eddleston and Gunnell155 Chowdhury et al reported the promising effects of a ban on class I pesticides in Bangladesh and a corresponding overall decrease in suicide rate in the region.Reference Chowdhury, Dewan, Verma, Knipe, Isha and Faiz156

Similarly, Sri Lanka and South Korea have achieved success through governmental regulations in the availability of pesticides and insecticides.Reference Cha, Chang, Choi and Lee5,Reference Gunnell, Knipe, Chang, Pearson, Konradsen and Lee157,Reference Knipe, Gunnell and Eddleston158 With our collective effort, there is no reason that Pakistan could not achieve the same. After the next three decades, a strikingly different review focusing on suicide rate reduction success may be reported. As noted above, the Punjab Government has taken the first steps to ban potentially harmful agents.115 The Federal Government of Pakistan must follow suit in steering the campaign against suicide in the right direction. In a recent paper, Zia emphasised the need for clear warning labels, phrases in local languages and symbols on pesticides and other hazardous chemicals. The author suggested that the advertisement must include safety warnings as for cigarettes, and a strict following of Food and Agriculture Organization of the United Nations guidelines should be implemented.Reference Zia159 The need for systemic media campaigns for awareness and safe pesticide is necessary. We believe that despite the recent step of passing the decriminalisation of suicide bill in the Senate, it will take a concerted effort to decrease stigma against suicide survivors.

Management of individual agents

A summary of the management of agents is as follows (see Table 5):


Organophosphate compounds are a diverse group of chemicals used in domestic, industrial and agricultural settings. Examples include insecticides and pesticides (malathion, parathion, etc.), herbicides (glyphosate, atrazine, etc.) and nerve gases (sarin, tabun, VX).Reference Lee160 Organophosphate poisoning is one of the most common methods used for suicide, and is a leading cause of death in young people in Pakistan, China, India, Sri Lanka and other Asian countries.Reference Arshad, Abid, Aziz, Anjum and Nadeem161Reference Yimaer, Chen, Zhang, Zhou, Fang and Jiang163 It is recognised as the principal mode of poisoning in southern Punjab, and accounts for 47–60% of instances reported in Sindh.Reference Ahmad, Ahad, Rashid and Ashiq164Reference Robb and Baker166 Data from other parts of the country suggest organophosphates as a cause of poisoning in 20 to 40% of cases.Reference Khurram and Mahmood50,Reference Rahim, Ullah, Haroon, Ashfaq and Afridi54,Reference Ali, Muhammad, Rahim, Rahman and Ullah165

Inhalation, ingestion or skin contact can lead to organophosphate poisoning. The organophosphate molecule binds and inactivates acetylcholinesterase enzyme in red blood cells. This leads to an overabundance of acetylcholine within both nicotinic and muscarinic synapses and the neuromuscular junctions.Reference Robb and Baker166 The nicotinic effects are rapid in onset and may include twitching of fine muscles, fasciculations and hyperreflexia, which may progressively lead to flaccid paralysis. Muscarinic receptors are located in both the sympathetic and parasympathetic nervous systems, and are usually slower in onset because of their action via G-protein-coupled receptors. Symptoms such as bronchorrhea, bronchoconstriction, excessive sweating, constricted pupils, abdominal cramps, involuntary defaecation and urination, tachycardia, QT prolongation, headaches, dizziness, drowsiness, confusion, anxiety, slurred speech, ataxia, psychosis, convulsions, coma, hypotension and respiratory depression can occur.Reference Eddleston, Singh and Buckley167Reference Asghar, Farooq, Sidra, Asghar and Ijaz169

The diagnosis of organophosphate poisoning is clinical and based on the presenting history, collateral information from the attendants and the clinical signs. Confirmation of organophosphate poisoning can be obtained by measuring plasma butyrylcholinesterase activity or acetylcholinesterase in whole blood; however, such assays are not readily available to inform clinical decision-making.Reference Eddleston, Buckley, Eyer and Dawson170 The first step is to decontaminate the patient and prevent further absorption via the eyes, skin or lungs. Personal protective equipment must be used to avoid exposure. The standard treatment of organophosphate poisoning is the reversal of muscarinic manifestations using atropine, followed by enzyme reactivation by pralidoxime. Frequent atropine doses or continuous infusion are used to clear excessive respiratory secretions and to treat bradycardia.Reference Clark, Goldfrank, Flomenbaum, Lewin, Howland, Hoffman and Nelson171 Atropine should be continued for 1–3 days after successful atropinisation. Pralidoxime facilitates the recovery of neuromuscular transmission at the nicotinic synapses. It significantly reduces atropine consumption in organophosphate poisoning, and signs of atropinisation may occur earlier with its use than without its administration.Reference Eyer172

In our analysis, mortality ranged from 10 to 27%. It was dependent on the amount of substance ingested, the time to reach an emergency department or time to initiation of treatment, and the use of a ventilator for assisted breathing.Reference Calvert, Plate, Das, Rosales, Shafey and Thomsen173 Other predictors of mortality include age >40 years, bradycardia, low pH, high glucose, high lactate dehydrogenase and low Glasgow Coma Scale score.Reference Khan, Ahmed and Khan44,Reference Ahmed, Das, Nadeem and Samal174

Aluminium phosphide

Aluminium phosphide is a highly toxic, solid fumigant insecticide and rodenticide used for grain conservation.Reference Karimani, Mohammadpour, Zirak, Rezaee, Megarbane and Tsatsakis175 It is referred to as wheat pills in Pakistan, and is also known as rice pills or rice tablets in other countries.Reference Navabi, Navabi, Aghaei, Shaahmadi and Heydari176,Reference Hosseinian, Pakravan, Rafiei and Feyzbakhsh177 It is not regulated by the government and is available for over-the-counter purchase without any restriction, making it an ideal agent for self-poisoning in the wheat-growing areas of northern and central Punjab.Reference Hassan, Shafique and Adil178 Studies have reported its use as an agent of suicide by ingestion from Rawalpindi,Reference Hassan, Shafique and Adil178 Kharian,Reference Ghazi75 Lahore,Reference Khan179 SahiwalReference Qureshi, Nadeem, Ahmed, Tariq, Rehman and Qasim78 and Peshawar in KPK.Reference Rahim, Ullah, Haroon, Ashfaq and Afridi54 In these areas, domestic conflicts or petty quarrels are a frequent cause of overdose, resulting in fatal outcomes.Reference Qureshi, Nadeem, Ahmed, Tariq, Rehman and Qasim78 The lack of an antidote makes it a prevalent and particularly lethal suicide agent.Reference Karimani, Mohammadpour, Zirak, Rezaee, Megarbane and Tsatsakis175

When exposed to moisture in the stomach after ingestion, phosphine gas is produced. This toxic gas inhibits cytochrome c oxidase and other vital cellular enzymes, disrupting several metabolic pathways and destabilising cell membranes. Disruption of mitochondrial function produces reactive hydroxyl radicals, leading to cellular hypoxia, free-radical-mediated injury and eventual cell death.Reference Navabi, Navabi, Aghaei, Shaahmadi and Heydari176,Reference Chugh, Chugh, Ram and Malhotra180 The presenting symptoms of aluminium phosphide poisoning may include epigastric pain, vomiting, diarrhoea, dizziness and dyspnoea.Reference Hassan, Shafique and Adil178 Multiorgan failure involving the heart, kidneys, lungs and liver later ensues, with metabolic acidosis, hepatic necrosis, renal failure, cardiac arrhythmia, congestive heart failure and hypotensive shock.Reference Chugh, Chugh, Ram and Malhotra180,Reference Hena, McCabe, Perez, Sharma, Sutton and Peek181

A silver nitrate test can be performed to confirm the diagnosis. Paper impregnated with silver nitrate turns black after exposure to the patient's breath or gastric contents, as a result of the reaction between phosphides and silver nitrate. The sensitivity of the test strip is 50% with a breath test and 100% with gastric contents.Reference Chugh, Ram, Chugh and Malhotra182

The treatment is supportive because of the absence of an antidote. Gastric lavage with potassium permanganate and mineral or coconut oil has been shown to reduce morbidity.Reference Shadnia, Rahimi, Pajoumand, Rasouli and Abdollahi183 Besides symptomatic treatment, renal replacement therapy in the early stage is also recommended.Reference Nasa, Gupta, Mangal, Nagrani, Raina and Yadav184

Aluminium phosphide is termed ‘agent of sure death’,Reference Mahajan and Pargal185 and the mortality rate ranged from 33 to 87% in our data.Reference Bogle, Theron, Brooks, Dargan and Redhead186 The lethal dose for an adult is 150–500 mg. The presence of vomiting, exposure of tablets before ingestion and early availability of supportive care can help decrease mortality.


Paraphenylenediamine is an ingredient of a compound commonly known as kala pathar or ‘Black Stone’ in Urdu. It is used as a chemical ingredient in temporary tattoo ink, fabrics, dark makeup, photocopying inks, printing, rubber products and gasoline. In the Indian subcontinent and North Africa, it is an ingredient of black henna for hair dye and tattoo ink.Reference Qasim, Ali, Baig and Moazzam84Reference Ansari, Khosa, Yadain, Shafi, Haq and Khalil86 Paraphenylenediamine is metabolised into benzoquinone diamine by cytochrome P450 peroxidase, and further oxidation results in the formation of Brandowaski's base. Both of these by-products are responsible for their toxicity.Reference Prabhakaran187,Reference Hill, Hatkevich, Kazimi and Sharp188 Paraphenylenediamine ingestion is another conventional means to commit suicide in southern Punjab.Reference Akbar, Khaliq, Malik, Shahzad, Tarin and Chaudhry189

The most common clinical presentations after paraphenylenediamine intoxication include cervicofacial oedema, rhabdomyolysis causing myoglobinuria, cola-coloured urine, oliguria and acute tubular necrosis leading to renal failure.Reference Suliman, Fadlalla, Nasr Mel, Beliela, Fesseha and Babiker190 A study of 150 cases of paraphenylenediamine poisoning from Sudan revealed angioneurotic oedema and conjunctival discolouration in 100% of cases, and acute kidney injury requiring haemodialysis in 60% of cases.Reference Kondle, Pathapati, Saginela, Malliboina and Makineed191

There is no antidote available for paraphenylenediamine poisoning. As the chemical is nondialysable, the mainstay of management remains supportive.Reference Umair, Amin and Urrehman192 The patient must be observed in the intensive care unit. Management includes early tracheostomy for cervicofacial oedema and intravenous fluids, with aggressive diuresis and urine alkalisation for renal failure.Reference Daga, Sinha, Mahapatra, Kumar, Lalmalsawma and Nayak193Reference Punjani195 Rhabdomyolysis may lead to acute tubular necrosis, requiring haemodialysis.

The outcome of paraphenylenediamine ingestion depends on the dose taken. The lethal dose of paraphenylenediamine is unknown, and estimates vary from 7 to 10 g.Reference Bowen196,Reference Jan, Khan, Khan, Khan and Fatima197 A large quantity (>7 g) might cause death within the first 6–24 h from angioneurotic oedema or cardiotoxicity.Reference Gude, Bansal, Ambegaonkar and Prajapati198 The mortality ranges from 21 to 47%.


This group included over-the-counter agents, prescription medicine, agents of abuse and household chemicals. This type of poisoning was more common in young patients (15–35 years) from urban backgrounds.Reference Khurram and Mahmood50,Reference Shoaib, Nadeem and Khan76,Reference Asif, Yusuf, Haider, Gul, Usman and Akbar77,Reference Khurram and Mahmood91,Reference Parkar Khan, Perez-Nunez, Shamim, Khan, Naseer and Feroze199 Males overdosed at a higher rate than females.Reference Patel, Shahid, Riaz, Kashif, Ayaz and Khan91,Reference Parkar Khan, Perez-Nunez, Shamim, Khan, Naseer and Feroze199 Benzodiazepines were the most common agent used for overdose;Reference Patel, Shahid, Riaz, Kashif, Ayaz and Khan91,Reference Goldsmith, Pellmar, Kleinman and Bunney116,Reference Jan, Khan, Khan, Khan and Fatima197 however, other agents used were NSAIDs, analgesics, sedatives, tricyclics, anti-emetics, antiallergics, anti-epileptics, oral hypoglycaemics, warfarin, digoxin, methamphetamine and cocaine.Reference Khurram and Mahmood50,Reference Patel, Shahid, Riaz, Kashif, Ayaz and Khan91,Reference Jan, Khan, Khan, Khan and Fatima197 Corrosives, kerosene oil, rubbing alcohol, copper sulphate, bleach, rat poison pills and home insecticide sprays were also used.Reference Imtiaz, Ali and Ali63,Reference Shoaib, Nadeem and Khan76,Reference Asif, Yusuf, Haider, Gul, Usman and Akbar77,Reference Patel, Shahid, Riaz, Kashif, Ayaz and Khan91,Reference Parkar Khan, Perez-Nunez, Shamim, Khan, Naseer and Feroze199 Most patients taking an overdose had an intention to commit suicide; however, other reasons for overdose were to gain attention, express distress or get revenge.Reference Khurram and Mahmood50,Reference Parkar, Dawani and Weiss200 The researchers interviewed a total of 80 individuals admitted after suicide overdose, to determine their intention to die, and noted that the patients with such an intention chose organophosphates because of its known high lethality.

The most common presentation was drowsiness owing to central nervous system depression; others presented with central nervous system stimulation or a mixed picture.Reference Patel, Shahid, Riaz, Kashif, Ayaz and Khan91 Heart rate, blood pressure, body temperature, respiratory rate, skin clamminess, pupillary reaction and neuromuscular abnormalities provided clues to the correct diagnosis.

Treatment includes decontamination and gastric lavage with activated charcoal. The use of the benzodiazepine antidote flumazenil remains controversial as it could precipitate withdrawal seizures in individuals who have developed tolerance from chronic use.Reference Weinbroum, Flaishon, Sorkine, Szold and Rudick201 Flumazenil use in paediatric benzodiazepine overdose may be used as young children are unlikely to be tolerant to benzodiazepines.Reference Shalansky, Naumann and Englander202 Haemodialysis, haemofiltration and exchange transfusion could facilitate removing the agents or chemicals from circulation. Supportive care is indicated for strict airway monitoring, gastrointestinal protection and the treatment of hypo- or hypertension.

Mortality varied from 2.5 to 25%, depending on the place of study. General medical wards reported lower death rates than intensive care units, likely related to the severity of the patient's condition.Reference Khurram and Mahmood50,Reference Rahim, Ullah, Haroon, Ashfaq and Afridi54 Mortality was also dependant on the level of care available in the centre where the patient was under treatment.

There are several limitations to this analysis. We considered papers in the English language, from only two electronic databases, and excluded single case reports in this retrospective analysis. Significant variations in the reported information in descriptive studies make it difficult to analyse or present the data in a meta-analysis. Limited data were available from Balochistan and Gilgit–Baltistan, and studies from other provinces also represented only larger cities. Risk factors were not available for extensive analysis. More comprehensive studies are required to explore how individual differences influence regional trends of suicide and other means of suicide that were not addressed in our review.

Summary and future directions

Our study found that there are striking regional and urban versus rural differences in the choice of agents used for suicide. As the suicide rate in Pakistan is rapidly increasing, we must take several steps to reverse the trend of the past three decades. We should launch customised mental health literacy and public health awareness campaigns across the country, to address the stigma against suicide and mental health. The success and acceptance of such endeavours will depend on partnership with local authorities, tribal or clan leaders, religious leaders and influential community figures. Print (newspapers, magazines, etc.), electronic (network television, radio, etc.) and social media (Facebook, Twitter, Instagram, YouTube, etc.) may enhance the dissemination of the message. Efforts are needed to enforce the existing national pesticide policy. There is a need to have regulations to restrict over-the-counter sales of potentially dangerous medications, such as benzodiazepines, opiates and opioid derivatives. Finally, our hospitals need consistent medical supplies and specialised equipment, along with training of medical staff, to manage victims adequately. These interventions are necessary to reduce morbidity and mortality related to suicide poisoning in this time of crisis.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article.

Author contributions

M.S., F.A., Z.F.B. and P.Z. identified review articles and planned the review. Z.S. analysed the data and wrote the Results section and the associated tables. M.S. and K.I.A. wrote the manuscript. Z.F.B. wrote the management section of the Discussion section and created the associated table. All authors contributed to and have approved the final manuscript.


This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Declaration of interest




Joint first authors.


National Center for Injury Prevention and Control. 10 Leading Causes of Death by Age Group, United States – 2017. Centers for Disease Control and Prevention, 2019 ( Scholar
World Health Organization (WHO). Mental Health and Substance Use: Suicide Data. WHO, 2019 ( Scholar
Cha, ES, Chang, SS, Choi, Y, Lee, WJ. Trends in pesticide suicide in South Korea, 1983–2014. Epidemiol Psychiatr Sci 2019; 29: e25.CrossRefGoogle ScholarPubMed
Demir, M. Trends in suicide methods by age group. Asia Pac Psychiatry 2018; 10(4): e12334.CrossRefGoogle ScholarPubMed
Ohberg, A, Lonnqvist, J, Sarna, S, Vuori, E, Penttila, A. Trends and availability of suicide methods in Finland. Proposals for restrictive measures. Br J Psychiatry 1995; 166(1): 3543.CrossRefGoogle ScholarPubMed
Snowdon, J. Differences between patterns of suicide in East Asia and the West. The importance of sociocultural factors. Asian J Psychiatr 2018; 37: 106–11.CrossRefGoogle ScholarPubMed
Abdullah, M, Khalily, MT, Ahmad, I, Hallahan, B. Psychological autopsy review on mental health crises and suicide among youth in Pakistan. Asia Pac Psychiatry 2018; 10(4): e12338.CrossRefGoogle ScholarPubMed
Shekhani, SS, Perveen, S, Hashmi, DE, Akbar, K, Bachani, S, Khan, MM. Suicide and deliberate self-harm in Pakistan: a scoping review. BMC Psychiatry 2018; 18: 44.CrossRefGoogle ScholarPubMed
United States Census Bureau. U.S. Census Bureau Current Population. United States Census Bureau, 2020 ( Scholar
Pakistan Bureau of Statistics. 6th Population and Housing Census 2017. Pakistan Bureau of Statistics, 2017 ( Scholar
Rehman, A, Jingdong, L, Shahzad, B, Chandio, AA, Hussain, I, Nabi, G, et al. Economic perspectives of major field crops of Pakistan: an empirical study. Pac Sci Rev B: Humanit Soc Sci 2015; 1(3): 145–58.Google Scholar
UNESCO Institute for Statistics. Literacy Rate, Adult Total (% of People Ages 15 and Above) - Pakistan 2017. The World Bank, 2020 ( Scholar
Hunter, R. Education in Pakistan. World Education Services, 2020 ( Scholar
Rehman, A, Jingdong, L, Hussain, I. The province-wise literacy rate in Pakistan and its impact on the economy. Pac Sci Rev B: Humanit Soc Sci 2015; 1(3): 140–4.Google Scholar
Zakaria, M, Jun, W, Ahmed, H. Effect of terrorism on economic growth in Pakistan: an empirical analysis. Econ Res Ekonomska Istraživanja 2019; 32(1): 1794–812.CrossRefGoogle Scholar
Khan, NH, Ju, Y, Hassan, ST. Modeling the impact of economic growth and terrorism on the human development index: collecting evidence from Pakistan. Environ Sci Pollut Res 2018; 25(34): 34661–73.CrossRefGoogle ScholarPubMed
World Economic Outlook. Unemployment Rate Percent - Pakistan 2021. International Monetary Fund, 2021 ( Scholar
Shah, Z. Underperforming on Most Social Development Indicators. The Express Tribune, 2017 ( Scholar
Anjum, A, Saeed Ali, T, Akber Pradhan, N, Khan, M, Karmaliani, R. Perceptions of stakeholders about the role of health system in suicide prevention in Ghizer, Gilgit-Baltistan, Pakistan. BMC Public Health 2020; 20: 991.CrossRefGoogle ScholarPubMed
Rej, A. Gilgit-Baltistan to Become a New Province of Pakistan, Announces Khan Government. The Diplomat, 2020 ( Scholar
Finlayson, C. Chapter 9.3: Pakistan and Bangladesh. In World Regional Geography: People, Places and Globalization. University of Minnesota Libraries Publishing, 2014.Google Scholar
Bukhari, SM. The Serenity of Ghanche: Of Mountains, Rivers and Valleys. Dawn, 2017 ( Scholar
Shah, SAM, Amjad, S. Cultural diversity in Pakistan: national vs provincial. Mediterr J Soc Sci 2011; 2: 331–44.Google Scholar
Pakistan Bureau of Statistics. Population by Religion. Pakistan Bureau of Statistics, [updated 9 Jan 2021; cited 9 Jan 2021. ( Scholar
Hussain, R. “Pakistan.” In The Oxford Encyclopedia of the Islamic World. Oxford Islamic Studies Online, 2021.Google Scholar
Gearing, RE, Lizardi, D. Religion and suicide. J Relig Health 2009; 48(3): 332–41.CrossRefGoogle ScholarPubMed
Khan, MM, Mian, AI. ‘The one truly serious philosophical problem’: ethical aspects of suicide. Int Rev Psychiatry 2010; 22(3): 288–93.CrossRefGoogle ScholarPubMed
Chaleby, KS. Issues in forensic psychiatry in Islamic jurisprudence. Bull Am Acad Psychiatry Law 1996; 24(1): 117–24.Google ScholarPubMed
Simpson, ME, Conklin, GH. Socioeconomic development, suicide and religion: a test of Durkheim's theory of religion and suicide. Soc Forces 1989; 67(4): 945–64.CrossRefGoogle Scholar
Faruqui, R, Afghan, S. P03-445 - suicide risk awareness in Pakistan: influence of religious, cultural, legal, socio-economic and interpersonal factors. Eur Psychiatry 2011; 26: 1615.CrossRefGoogle Scholar
Khan, MM, Hyder, AA. Suicides in the developing world: case study from Pakistan. Suicide Life Threat Behav 2006; 36(1): 7681.CrossRefGoogle ScholarPubMed
Lester, D. Suicide and Islam. Arch Suicide Res 2006; 10(1): 7797.CrossRefGoogle ScholarPubMed
Eskin, M, AlBuhairan, F, Rezaeian, M, Abdel-Khalek, AM, Harlak, H, El-Nayal, M, et al. Suicidal thoughts, attempts and motives among university students in 12 Muslim-majority countries. Psychiatr Q 2019; 90(1): 229–48.CrossRefGoogle ScholarPubMed
Karamouzian, M, Rostami, M. Suicide statistics in Iran: let's get specific. Am J Mens Health 2019; 13(1): 1557988318807079.CrossRefGoogle ScholarPubMed
Arya, V, Page, A, Dandona, R, Vijayakumar, L, Mayer, P, Armstrong, G. The geographic heterogeneity of suicide rates in India by religion, caste, tribe, and other backward classes. Crisis 2019; 40(5): 370–4.CrossRefGoogle ScholarPubMed
Pritchard, C, Iqbal, W, Dray, R. Undetermined and accidental mortality rates as possible sources of underreported suicides: population-based study comparing Islamic countries and traditionally religious Western countries. BJPsych Open 2020; 6(4): e56.CrossRefGoogle ScholarPubMed
Institute for Health Metrics and Evaluation . GBD Results Tool: Suicide by Gender 2018. Global Health Data Exchange, 2018 ( Scholar
Bachmann, S. Epidemiology of suicide and the psychiatric perspective. Int J Environ Res Public Health 2018; 15(7): 1425.CrossRefGoogle ScholarPubMed
Khan, MM, Mahmud, S, Karim, MS, Zaman, M, Prince, M. Case-control study of suicide in Karachi, Pakistan. Br J Psychiatry 2008; 193(5): 402–5.CrossRefGoogle ScholarPubMed
Yousafzai, AW, Yousafzai, S, Khan, SA. Rising suicide rates in Pakistan: is it about time to break the silence? J Ayub Med Coll Abbottabad 2020; 32(2): 153–4.Google ScholarPubMed
Khan, MM, Ahmed, A, Khan, SR. Female suicide rates in Ghizer, Pakistan. Suicide Life Threat Behav 2009; 39(2): 227–30.CrossRefGoogle ScholarPubMed
Anjum, A, Saeed Ali, T, Akber Pradhan, N, Khan, M, Karmaliani, R. Perceptions of stakeholders about the role of health system in suicide prevention in Ghizer, Gilgit-Baltistan, Pakistan. BMC Public Health 2020; 20: 991.CrossRefGoogle ScholarPubMed
Hassan, T. Why Are More Pakistanis Taking Their Own Lives? Dawn, 2019 ( Scholar
World Health Organization (WHO). The World Health Report 2004 - Changing History. WHO, 2004 ( Scholar
Bhatti, N, Khan, DA, Saleem, S, Ijaz, A, Aamir, M. Frequency of drug poisoning in adults at tertiary care hospital. Wah Cantt. Pak J Pathol 2015; 26(1): 2734.Google Scholar
Maqbool, F, Satti, AI, Jeelani, RA, Baqai, HZ. Organophosphate poisoning – clinical profile. J Rawal Med College (KRMC) 2015; 19(1): 15–9.Google Scholar
Khurram, M, Mahmood, N. Deliberate self-poisoning: experience at a medical unit. J Pak Med Assoc 2008; 58(8): 455–7.Google Scholar
Tahir, MN, Akbar, AH, Naseer, R, Khan, QO, Khan, F, Yaqub, I. Suicide and attempted suicide trends in Mianwali, Pakistan: social perspective. East Mediterr Health J 2014; 19(3): S111–4.Google ScholarPubMed
Naheed, T, Akbar, N, Akbar, N, Munir, R. Acute poisoning in the city of Punjab - how can we help these souls? J Fatima Jinnah Med Coll Lahore 2007; 1(3–4): 56–8.Google Scholar
Ali, Z, Afridi, MAR, Muhammad, R, Rahim, A, Rahman, SKU, Ullah, N, et al. Outcome and predictors of in-hospital mortality in patients presenting with acute poisoning to a teaching hospital. J Postgrad Med Inst 2018; 32(2): 155–61.Google Scholar
Rahim, F, Ullah, F, Haroon, M, Ashfaq, M, Afridi, AK. Acute poisoning treated in medical intensive care unit. Gomal J Med Sci 2016; 14: 129–32.Google Scholar
Shaikh, MA. Mortality in patients presenting with organophosphorus poisoning at Liaquat university of medical and health sciences. Pak J Med Sci 2011; 27(5): 1022–4.Google Scholar
Imran, S, Awan, EA, Memon, MIS, Memon, A. Frequency and outcomes of organophosphate poisoning at tertiary care hospital in Nawabshah. J Liaquat Uni Med Health Sci 2017; 16(2): 118–20.Google Scholar
Faiz, MS, Mughal, S, Memon, AQ. Acute and late complications of organophosphate poisoning. J Coll Physicians Surg Pak 2011; 21(5): 288–90.Google ScholarPubMed
Shaikh, MA, Ujjan, ID, Memon, SH. Evaluation of patients with organophosphorus poisoning at a tertiary care hospital of Sindh. Med Channel 2011; 17(3): 51–3.Google Scholar
Amir, A, Haleem, F, Mahesar, G, Sattar, RA, Qureshi, T, Syed, JG, et al. Epidemiological, poisoning characteristics and treatment outcomes of patients admitted to the national poisoning control centre at Karachi, Pakistan: a six month analysis. Cureus 2019; 11(11): e6229.Google ScholarPubMed
Khan, NU, Khan, UR, Feroze, A, Khan, SA, Ali, N, Ejaz, K, et al. Trends of acute poisoning: 22 years experience from a tertiary care hospital in Karachi, Pakistan. J Pak Med Assoc 2016; 66(10): 1237–42.Google ScholarPubMed
Ahmed, A, Ali, L, Shehbaz, L, Nasir, S, Rizvi, SRH, Aman, MZ, et al. Prevalence and characteristics of organophosphate poisoning at a tertiary care centre in Karachi, Pakistan. Pak J Surg 2016; 32(4): 269–73.Google Scholar
Imtiaz, F, Ali, M, Ali, L. Prevalence of chemical poisoning for suicidal attempts in Karachi, Pakistan. Emerg Med (Los Angel) 2015; 5: 247.Google Scholar
Asghar, SP, Ather, N, Farooq, M, Sidra, S, Asghar, S, Ijaz, A. Presentation and management of organophosphate poisoning in an intensive care unit. Pak Armed Forces Med J 2014; 64(1): 134–8.Google Scholar
Bashir, F, Ara, J, Kumar, S. Deliberate self poisoning at national poisoning control centre. J Liaquat Univ Med Health Sci 2014; 13(1): 38.Google Scholar
Ali, P, Anwer, A, Bashir, B, Jabeen, R, Haroon, H, Makki, K. Clinical attern and outcome of organophosphorus poisoning. J. Liaquat Univ. Med. Health Sci 2012; 11(1): 15–8.Google Scholar
Ather, NA, Ara, J, Khan, EA, Sattar, RA, Durrani, R. Acute organophosphate insecticide poisoning. Journal of Surgery Pakistan (International) 2008; 13(2): 71–4.Google Scholar
Turabi, A, Danyal, A, Hasan, S, Durrani, A, Ahmed, M. Organophosphate poisoning in the urban population; study conducted at National Poison Control Center Karachi. Biomedica 2008; 24: 124–9.Google Scholar
Hussain, AM, Sultan, ST. Organophosphorus insecticide poisoning: management in surgical intensive care unit. J Coll Physicians Surg Pak 2005; 15(2): 100–2.Google ScholarPubMed
Jamil, H. Acute poisoning - A review of 1900 cases. J Pak Med Assoc 1990; 40: 131.Google ScholarPubMed
Jamil, H. Organophosphorus insecticide poisoning. J Pak Med Assoc 1989; 39: 2731.Google ScholarPubMed
Khan, NK, Shamim, H. Deliberate self harm due to organophosphates. J Pak Inst Med Sci. (JPIMS) 2003; 14(2): 784–9.Google Scholar
Hassan, A, Manzoor, MS, Shafique, M, Adil, . Wheat pill poisoning: clinical manifestation and its outcome. J Rawal Med Univ 2014; 18(1): 4951.Google Scholar
Iftikhar, R, Tariq, KM, Saeed, F, Khan, MB, Babar, NF. Wheat pill: characteristics and outcome. Pak Armed Forces Med J 2011; 61(3): 350–3.Google Scholar
Ghazi, MA. Wheat pill [aluminum phosphide] poisoning; commonly ignored dilemma. A comprehensive clinical review. Professional Med J -Q 2013; 20(6): 855–63.Google Scholar
Shoaib, S, Nadeem, M, Khan, Z. Causes and outcome of suicidal cases presented to a medical ward. Ann King Edward Med Univ 2016; 11(1): 30–2.Google Scholar
Asif, A, Yusuf, F, Haider, K, Gul, H, Usman, S, Akbar, S, et al. Epidemiology of attempted suicides in emergency of Mayo Hospital in 2004. Ann King Edward Med Univ 2005; 11(4): 384–6.Google Scholar
Qureshi, MA, Nadeem, S, Ahmed, T, Tariq, F, Rehman, H, Qasim, AP. Aluminium phosphide poisoning: clinical profile and outcome of patients admitted in a tertiary care hospital. Ann Punjab Med Coll 2018; 12(3): 191–4.Google Scholar
Akram, A, Shahid, RA, Tariq, M. Kala Pathar (Paraphenylene Diamine) poisoning; Role of tracheostomy: our experience at DHQ hospitals. Pak J Med Health Sci. 2018; 12(2): 865–6.Google Scholar
Tanweer, S, Saeed, M, Zaidi, S, Aslam, W. Clinical profile and outcome of Paraphenylene Diamine. J Coll Physicians Surg Pak. 2018; 28(5): 374–7.CrossRefGoogle ScholarPubMed
Haider, SH, Sultan, A, Salman, Z, Waris, S, Bandesha, Y. Paraphenylenediamine poisoning: clinical presentations and outcomes. Anaesth Pain & Intensive Care 2017; 21(4): 43–7.Google Scholar
Khan, MA, Akram, S, Shah, HBU, Hamdani, SAM, Khan, M. Epidemic of Kala Pathar (Paraphenylene Diamine) poisoning: an emerging threat in Southern Punjab. J Coll Physicians Surg Pak. 2018; 28(1): 44–7.CrossRefGoogle ScholarPubMed
Ishtiaq, R, Shafiq, S, Imran, A, Masroor Ali, Q, Khan, R, Tariq, H, et al. Frequency of acute hepatitis following acute paraphenylene diamine intoxication. Cureus 2017; 9(4): e1186.Google ScholarPubMed
Qasim, AP, Ali, AM, Baig, A, Moazzam, MS. Emerging trend of self harm by using ‘kala pathar’ hair dye (paraphenylene diamine): an epidemiological study. Ann Punjab Med Coll 2016; 10(1): 2630.Google Scholar
Akbar, K, Iqbal, J, Rehman, H, Iqbal, R. Acute renal failure among kala pathar poisoning. J Sheikh Zayed Med Coll. 2017; 8(2): 1153–6.Google Scholar
Ansari, RZ, Khosa, AH, Yadain, SM, Shafi, S, Haq, AU, Khalil, ZH. Incidence of paraphenylene diamine poisoning in three district headquarter hospitals of Pakistan. J Ayub Med Coll Abbottabad 2019; 31(4): 544–7.Google ScholarPubMed
Khan, H, Khan, N, Khan, N, Ahmad, I, Shah, F, Rahman, AU, et al. Clinical presentation and outcome of patients with paraphenylenediamine (kala-pathar) poisoning. Gomal J Med Sci 2016; 14: 36.Google Scholar
Kazi, MA, Shaikh, AR, Samad, A, Bibi, I, Khan, M. Kala pathar (Paraphenylene Diamine) poisoning: an ICU based observational study at Hyderabad, Pakistan. Indo Am. J. P. Sci 2018; 5(9): 9334–7.Google Scholar
Khuhro, BA, Khaskheli, MS, Shaikhet, AA. Paraphenylene diamine poisoning: our experience at PMC hospital Nawabshah. Anaesth Pain & Intensive Care 2012; 16(3): 243–6.Google Scholar
Hashmi, MU, Ali, M, Ullah, K, Aleem, A, Khan, IH. Clinico-epidemiological characteristics of corrosive ingestion: a cross sectional study at a tertiary care hospital of Multan, South Punjab Pakistan. Cureus 2018; 10(5): e2704.Google Scholar
Patel, MJ, Shahid, M, Riaz, M, Kashif, W, Ayaz, SI, Khan, MS, et al. Drug overdose: a wake up call! Experience at a tertiary care centre in Karachi, Pakistan. J Pak Med Assoc 2008; 58(6): 298301.Google Scholar
Khan, MM, Reza, H. Benzodiazepine self-poisoning in Pakistan: implications for prevention and harm reduction. J Pak Med Assoc 1998; 48: 293–5.Google ScholarPubMed
Ahmed, Z, QNisa, A, Yousafzai, SK, Chaudhry, J. Trends and patterns of suicide in people of Chitral, Khyber Pakhtunkhwa, Pakistan. Khyber Med Univ J 2016; 8(2): 72–7.Google Scholar
Khan, MM, Ahmed, A, Khan, SR. Female suicide rates in Ghizer, Pakistan. Suicide Life Threat Behav 2009; 39(2): 227–30.CrossRefGoogle ScholarPubMed
Miller, V, Yusuf, S, Chow, CK, Dehghan, M, Corsi, DJ, Lock, K, et al. Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet Glob Health 2016; 4(10): e695703.CrossRefGoogle ScholarPubMed
Mohammad, N, Mohammad Rasul, J, Hizbullah, K. Pesticide use in Swat Valley, Pakistan. Mt Res Dev 2008; 28(3): 201–4.Google Scholar
Ullah, R, Asghar, R, Baqar, M, Mahmood, A, Ali, SN, Sohail, M, et al. Assessment of organochlorine pesticides in the Himalayan riverine ecosystems from Pakistan using passive sampling techniques. Environ Sci Pollut Res Int 2019; 26(6): 6023–37.CrossRefGoogle ScholarPubMed
Ali, MA. The Pesticides Registered with Recommendations for Safe Handling and Use in Pakistan. Pakistan Agricultural Research Council, 2018.Google Scholar
Jabbar, A, Mallick, S. Institutional arrangements for pesticide monitoring and research. In Pesticides and Environment Situation in Pakistan: 6–8. Sustainable Development Policy Institute, 1994.Google Scholar
Mughal, FH. Environmental Impact of Pesticide Overuse. Dawn, 2018 ( Scholar
Global Greengrants Funds. Poisoned by Pesticides in Pakistan. Global Greengrants Funds, 2011 ( Scholar
Ahmad, A, Shahid, M, Khalid, S, Zaffar, H, Naqvi, T, Pervez, A, et al. Residues of endosulfan in cotton growing area of Vehari, Pakistan: an assessment of knowledge and awareness of pesticide use and health risks. Environ Sci Pollut Res Int 2019; 26(20): 20079–91.CrossRefGoogle ScholarPubMed
Saeed, MF, Shaheen, M, Ahmad, I, Zakir, A, Nadeem, M, Chishti, AA, et al. Pesticide exposure in the local community of Vehari District in Pakistan: an assessment of knowledge and residues in human blood. Sci Total Environ 2017; 587–8: 137–44.CrossRefGoogle Scholar
Khan, M, Mahmood, HZ, Damalas, CA. Pesticide use and risk perceptions among farmers in the cotton belt of Punjab, Pakistan. Crop Protection 2015; 67: 184–90.CrossRefGoogle Scholar
Medical and Health Services, Departments, Karachi Metropolitan Corporation 2021. ( Scholar
Amir, A, Raza, A, Qureshi, T, Mahesar, GB, Jafferi, S, Haleem, F, et al. Organophosphate poisoning: demographics, severity scores and outcomes from national poisoning control centre, Karachi. Cureus 2020; 12(5): e8371.Google ScholarPubMed
Khan, M, Damalas, CA. Occupational exposure to pesticides and resultant health problems among cotton farmers of Punjab, Pakistan. Int J Environ Health Res 2015; 25(5): 508–21.CrossRefGoogle ScholarPubMed
Bakhsh, K, Ahmad, N, Kamran, MA, Hassan, S, Abbas, Q, Saeed, R, et al. Occupational hazards and health cost of women cotton pickers in Pakistani Punjab. BMC Public Health 2016; 16: 961.CrossRefGoogle ScholarPubMed
Boedeker, W, Watts, M, Clausing, P, Marquez, E. The global distribution of acute unintentional pesticide poisoning: estimations based on a systematic review. BMC Public Health 2020; 20: 1875.CrossRefGoogle ScholarPubMed
Abdelraheem, MB, El-Tigani, MA, Hassan, EG, Ali, MA, Mohamed, IA, Nazik, AE. Acute renal failure owing to paraphenylene diamine hair dye poisoning in Sudanese children. Ann Trop Paediatr 2009; 29(3): 191–6.CrossRefGoogle ScholarPubMed
Abdelraheem, M, Ali, ET, Hussien, R, Zijlstra, E. Paraphenylene diamine hair dye poisoning in an adolescent. Toxicol Ind Health 2011; 27(10): 911–3.CrossRefGoogle Scholar
Ismaeel, T. Kala Pathar Rains Black Death on DG Khan. The Express Tribune, 2019 ( Scholar
Birmani, TS. 156 Women Attempted Suicide by Consuming ‘Kala Pathar’ in Dera Ghazi Khan Last Year. Dawn, 2018 ( Scholar
Ahmed, S. Kala Pathar Trade Banned to Stem Suicide Cases. Dawn, 2017 ( Scholar
INP. Kala Pathar Banned to Stop Suicides in S Punjab. The Nation, 2018 ( Scholar
Institute of Medicine Committee on Pathophysiology Prevention of Adolescent Adult Suicide. Reducing Suicide: A National Imperative (eds Goldsmith, SK, Pellmar, TC, Kleinman, AM, Bunney, WE). National Academies Press (US), 2002.Google Scholar
Shah, N. Suicide: A Plague in Balochistan. Daily Times, 2018 ( Scholar
Ali, M, Abbasi, BH, Ahmad, N, Fazal, H, Khan, J, Ali, SS. Over-the-counter medicines in Pakistan: misuse and overuse. Lancet 2020; 395(10218): 116.CrossRefGoogle ScholarPubMed
Knipe, D, Williams, AJ, Hannam-Swain, S, Upton, S, Brown, K, Bandara, P, et al. Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: a systematic review and meta-analysis. PLoS Med 2019; 16(10): e1002905-e.CrossRefGoogle ScholarPubMed
Hom, MA, Stanley, IH, Duffy, ME, Rogers, ML, Hanson, JE, Gutierrez, PM, et al. Investigating the reliability of suicide attempt history reporting across five measures: a study of US military service members at risk of suicide. J Clin Psychol 2019; 75(7): 1332–49.CrossRefGoogle ScholarPubMed
Hom, MA, Joiner, TE, Bernert, RA. Limitations of a single-item assessment of suicide attempt history: implications for standardized suicide risk assessment. Psychol Assess 2016; 28(8): 1026–30.CrossRefGoogle ScholarPubMed
Naveed, S, Qadir, T, Afzaal, T, Waqas, A. Suicide and its legal implications in Pakistan: a literature review. Cureus 2017; 9(9): e1665-e.Google ScholarPubMed
Hausmann, R, Tyson, LDA, Zahidi, S (eds). The Global Gender Gap Report 2012. World Economic Forum Geneva, 2012 ( Scholar
Chauhan, K. Patriarchal Pakistan: women's representation, access to resources, and institutional practices. In Gender Inequality in the Public Sector in Pakistan: Representation and Distribution of Resources (ed. Chauhan, K): 5787. Palgrave Macmillan, 2014.CrossRefGoogle Scholar
Ali, TS, Krantz, G, Gul, R, Asad, N, Johansson, E, Mogren, I. Gender roles and their influence on life prospects for women in urban Karachi, Pakistan: a qualitative study. Glob Health Action 2011; 4: 7448.CrossRefGoogle ScholarPubMed
Georgas, JE, Berry, JW, Van de Vijver, FJ, Kağitçibaşi, ÇE, Poortinga, YH. Families Across Cultures: A 30-Nation Psychological Study. Cambridge University Press, 2006.CrossRefGoogle Scholar
Rabbani, F, Qureshi, F, Rizvi, N. Perspectives on domestic violence: case study from Karachi, Pakistan. East Mediterr Health J 2008; 14(2): 415–26.Google ScholarPubMed
Gill, R, Stewart, DE. Relevance of gender-sensitive policies and general health indicators to compare the status of South Asian women's health. Womens Health Issues 2011; 21(1): 12–8.CrossRefGoogle ScholarPubMed
Shahid, M, Iqbal, R, Khan, MM, Khan, MZ, Shamsi, US, Nakeer, R. Risk factors for deliberate self-harm in patients presenting to the emergency departments of Karachi. J Coll Physicians Surg Pak 2015; 25(1): 50–5.Google ScholarPubMed
Cheng, Q, Chen, F, Yip, PS. Media effects on suicide methods: a case study on Hong Kong 1998-2005. PLoS One 2017; 12(4): e0175580.CrossRefGoogle ScholarPubMed
Ruder, TD, Hatch, GM, Ampanozi, G, Thali, MJ, Fischer, N. Suicide announcement on Facebook. Crisis 2011; 32(5): 280–2.CrossRefGoogle ScholarPubMed
Sun, FK, Lu, CY, Tseng, YS, Chiang, CY. Factors predicting recovery from suicide in attempted suicide patients. J Clin Nurs 2017; 26(23–4): 4404–12.CrossRefGoogle ScholarPubMed
Gearing, RE, Alonzo, D. Religion and suicide: new findings. J Relig Health 2018; 57(6): 2478–99.CrossRefGoogle ScholarPubMed
Rezaeian, M. Islam and suicide: a short personal communication. Omega (Westport) 2008; 58(1): 7785.CrossRefGoogle Scholar
Pritchard, C, Amanullah, S. An analysis of suicide and undetermined deaths in 17 predominantly Islamic countries contrasted with the UK. Psychol Med 2007; 37(3): 421–30.CrossRefGoogle ScholarPubMed
Jordans, MJ, Kaufman, A, Brenman, NF, Adhikari, RP, Luitel, NP, Tol, WA, et al. Suicide in South Asia: a scoping review. BMC Psychiatry 2014; 14: 358.CrossRefGoogle ScholarPubMed
Khezeli, M, Hazavehei, SM, Ariapooran, S, Ahmadi, A, Soltanian, A, Rezapur-Shahkolai, F. Individual and social factors related to attempted suicide among women: a qualitative study from Iran. Health Care Women Int 2019; 40(3): 295313.CrossRefGoogle ScholarPubMed
Cole, AB, Littlefield, AK, Gauthier, JM, Bagge, CL. Impulsivity facets and perceived likelihood of future suicide attempt among patients who recently attempted suicide. J Affect Disord 2019; 257: 195–9.CrossRefGoogle ScholarPubMed
Celik, M, Kalenderoglu, A, Almis, H, Turgut, M. Copycat suicides without an intention to die after watching TV programs: two cases at five years of age. Noro Psikiyatri Arsivi 2016; 53(1): 83–4.CrossRefGoogle Scholar
Ladwig, KH, Kunrath, S, Lukaschek, K, Baumert, J. The railway suicide death of a famous German football player: impact on the subsequent frequency of railway suicide acts in Germany. J Affect Disord 2012; 136(1–2): 194–8.CrossRefGoogle ScholarPubMed
Koburger, N, Mergl, R, Rummel-Kluge, C, Ibelshauser, A, Meise, U, Postuvan, V, et al. Celebrity suicide on the railway network: can one case trigger international effects? J Affect Disord 2015; 185: 3846.CrossRefGoogle ScholarPubMed
Wang, W, Chen, X, Li, S, Yan, H, Yu, B, Xu, Y. Cusp catastrophe modeling of suicide behaviors among people living with HIV in China. Nonlinear Dynamics Psychol Life Sci 2019; 23(4): 491515.Google ScholarPubMed
Mirza, I, Jenkins, R. Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. BMJ 2004; 328(7443): 794.CrossRefGoogle ScholarPubMed
Hansen, H, Braslow, J, Rohrbaugh, RM. From cultural to structural competency-training psychiatry residents to act on social determinants of health and institutional racism. JAMA Psychiatry 2018; 75(2): 117–8.CrossRefGoogle ScholarPubMed
Metzl, JM, Hansen, H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med 2014; 103: 126–33.CrossRefGoogle ScholarPubMed
Kirmani, N. The Spectre of Inequality. The News International, 2020 ( Scholar
Shams, K, Kadow, A. Income inequality, remittances and economic wellbeing in rural Pakistan: linkages and empirical evidence. Asia-Pac J Reg Sci 2020; 4(2): 499519.CrossRefGoogle Scholar
Li, M, Katikireddi, SV. Urban-rural inequalities in suicide among elderly people in China: a systematic review and meta-analysis. Int J Equity Health 2019; 18(1): 2.CrossRefGoogle ScholarPubMed
Varshney, M, Gupta, R, Balhara, YPS. Yes, India has done it: decriminalization of suicide in India. Asian J Psychiatry 2015; 17: 103.CrossRefGoogle ScholarPubMed
Majeed, MH, Amir Sherazi, SA, Afzal, MY. Decriminalization of suicide in Pakistan - treatment not punishment. Asian J Psychiatr 2018; 35: 67.CrossRefGoogle Scholar
Our, Correspondent. Dunya News TV. Treatment, Not Punishment: Senate Passes Bill to Decriminalise Attempted Suicide. 2018 ( Scholar
Munawar, K, Abdul Khaiyom, JH, Bokharey, IZ, Park, MS, Choudhry, FR. A systematic review of mental health literacy in Pakistan. Asia Pac Psychiatry 2020; 12(4): e12408.CrossRefGoogle ScholarPubMed
Cha, ES, Chang, SS, Gunnell, D, Eddleston, M, Khang, YH, Lee, WJ. Impact of paraquat regulation on suicide in South Korea. Int J Epidemiol 2016; 45(2): 470–9.CrossRefGoogle ScholarPubMed
Gunnell, D, Fernando, R, Hewagama, M, Priyangika, WD, Konradsen, F, Eddleston, M. The impact of pesticide regulations on suicide in Sri Lanka. Int J Epidemiol 2007; 36(6): 1235–42.CrossRefGoogle ScholarPubMed
Eddleston, M, Gunnell, D. Preventing suicide through pesticide regulation. Lancet Psychiatry 2020; 7(1): 911.CrossRefGoogle ScholarPubMed
Chowdhury, FR, Dewan, G, Verma, VR, Knipe, DW, Isha, IT, Faiz, MA, et al. Bans of WHO class I pesticides in Bangladesh-suicide prevention without hampering agricultural output. Int J Epidemiol 2018; 47(1): 175–84.CrossRefGoogle Scholar
Gunnell, D, Knipe, D, Chang, SS, Pearson, M, Konradsen, F, Lee, WJ, et al. Prevention of suicide with regulations aimed at restricting access to highly hazardous pesticides: a systematic review of the international evidence. Lancet Glob Health 2017; 5(10): e1026–37.CrossRefGoogle ScholarPubMed
Knipe, DW, Gunnell, D, Eddleston, M. Preventing deaths from pesticide self-poisoning-learning from Sri Lanka's success. Lancet Glob Health 2017; 5(7): e651–2.CrossRefGoogle ScholarPubMed
Zia, S. Pesticide Policy. eSocialSciences 2016; Working papers: id9077 ( Scholar
Lee, EC. Clinical manifestations of sarin nerve gas exposure. JAMA 2003; 290(5): 659–62.CrossRefGoogle ScholarPubMed
Arshad, S, Abid, F, Aziz, HA, Anjum, R, Nadeem, I. Specific poisons in Pakistan: a mini review. Res Pharm Health Sci 2016; 2(3): 179–86.Google Scholar
Najeeb, K. Pattern of suicide. Causes and methods employed. J Coll Physicians Surg Pak 2001; 11: 759–61.Google Scholar
Yimaer, A, Chen, G, Zhang, M, Zhou, L, Fang, X, Jiang, W. Childhood pesticide poisoning in Zhejiang, China: a retrospective analysis from 2006 to 2015. BMC Public Health 2017; 17: 602.CrossRefGoogle ScholarPubMed
Ahmad, R, Ahad, K, Rashid, I, Ashiq, M. Acute poisoning due to commercial pesticides in Multan. Pak J Med Sci 2002; 18(3): 227–31.Google Scholar
Ali, Z AM, Muhammad, R, Rahim, A, Rahman, SKU, Ullah, N, et al. Outcome and predictors of in-hospital mortality in patients presenting with acute poisoning to a teaching hospital. J Postgrad Med Inst. 2018; 32(2): 155–61.Google Scholar
Robb, EL, Baker, MB. Organophosphate Toxicity. StatPearls Publishing, 2020 ( ScholarPubMed
Eddleston, M, Singh, S, Buckley, N. Organophosphorus poisoning (acute). Clin Evid 2004; 12: 1941–53.Google Scholar
Eddleston, M, Singh, S, Buckley, N. Organophosphorus poisoning (acute). Clin Evid 2005; 13: 1744–55.Google Scholar
Asghar, SP AN, Farooq, M, Sidra, , Asghar, S, Ijaz, A. Presentation and management of organophosphate poisoning in an intensive care unit. Pak Armed Forces Med J. 2014; 64(1): 134–8.Google Scholar
Eddleston, M, Buckley, NA, Eyer, P, Dawson, AH. Management of acute organophosphorus pesticide poisoning. Lancet 2008; 371(9612): 597607.CrossRefGoogle ScholarPubMed
Clark, RF. Insecticides: organic phosphorous compounds and carbamates. In Goldfrank's Toxicologic Emergencies (eds Goldfrank, LR, Flomenbaum, NE, Lewin, NA, Howland, MA, Hoffman, RS, Nelson, LS): 1346–60. McGraw-Hill, 2002.Google Scholar
Eyer, P. The role of oximes in the management of organophosphorus pesticide poisoning. Toxicol Rev 2003; 22(3): 165–90.CrossRefGoogle ScholarPubMed
Calvert, GM, Plate, DK, Das, R, Rosales, R, Shafey, O, Thomsen, C, et al. Acute occupational pesticide-related illness in the US, 1998–1999: surveillance findings from the SENSOR-pesticides program. Am J Ind Med 2004; 45(1): 1423.CrossRefGoogle ScholarPubMed
Ahmed, SM, Das, B, Nadeem, A, Samal, RK. Survival pattern in patients with acute organophosphate poisoning on mechanical ventilation: a retrospective intensive care unit-based study in a tertiary care teaching hospital. Indian J Anaesth 2014; 58(1): 11–7.CrossRefGoogle Scholar
Karimani, A, Mohammadpour, AH, Zirak, MR, Rezaee, R, Megarbane, B, Tsatsakis, A, et al. Antidotes for aluminum phosphide poisoning - an update. Toxicol Rep 2018; 5: 1053–9.CrossRefGoogle ScholarPubMed
Navabi, SM, Navabi, J, Aghaei, A, Shaahmadi, Z, Heydari, R. Mortality from aluminum phosphide poisoning in Kermanshah Province, Iran: characteristics and predictive factors. Epidemiol Health 2018; 40: e2018022.CrossRefGoogle ScholarPubMed
Hosseinian, A, Pakravan, N, Rafiei, A, Feyzbakhsh, SM. Aluminum phosphide poisoning known as rice tablet: a common toxicity in North Iran. Indian J Med Sci 2011; 65(4): 143–50.CrossRefGoogle ScholarPubMed
Hassan, A MM, Shafique, M, Adil, . Wheat pill poisoning: clinical manifestation and its outcome. Journal of Rawalpindi Medical College. 2014; 18(1): 4951.Google Scholar
Khan, ZU. Rise in Wheat Pill Poisoning: Study. Dawn, 2008 ( Scholar
Chugh, SN, Chugh, K, Ram, S, Malhotra, KC. Electrocardiographic abnormalities in aluminium phosphide poisoning with special reference to its incidence, pathogenesis, mortality and histopathology. J Indian Med Assoc 1991; 89(2): 32–5.Google ScholarPubMed
Hena, Z, McCabe, ME, Perez, MM, Sharma, M, Sutton, NJ, Peek, GJ, et al. Aluminum phosphide poisoning: successful recovery of multiorgan failure in a pediatric patient. Int J Pediatr Adolesc Med 2018; 5(4): 155–8.CrossRefGoogle ScholarPubMed
Chugh, SN, Ram, S, Chugh, K, Malhotra, KC. Spot diagnosis of aluminium phosphide ingestion: an application of a simple test. J Assoc Physicians India 1989; 37(3): 219–20.Google ScholarPubMed
Shadnia, S, Rahimi, M, Pajoumand, A, Rasouli, MH, Abdollahi, M. Successful treatment of acute aluminium phosphide poisoning: possible benefit of coconut oil. Hum Exp Toxicol 2005; 24(4): 215–8.CrossRefGoogle ScholarPubMed
Nasa, P, Gupta, A, Mangal, K, Nagrani, SK, Raina, S, Yadav, R. Use of continuous renal replacement therapy in acute aluminum phosphide poisoning: a novel therapy. Ren Fail 2013; 35(8): 1170–2.CrossRefGoogle ScholarPubMed
Mahajan, VV, Pargal, L. Aluminium phosphide poisoning: an agent of sure death. Indian J Forensic Med Toxicol 2012; 6: 231–5.Google Scholar
Bogle, RG, Theron, P, Brooks, P, Dargan, PI, Redhead, J. Aluminium phosphide poisoning. Emergency Med J 2006; 23(1): e3.CrossRefGoogle ScholarPubMed
Prabhakaran, AC. Paraphenylene diamine poisoning. Indian J Pharmacol 2012; 44(3): 423–4.CrossRefGoogle ScholarPubMed
Hill, RM, Hatkevich, CE, Kazimi, I, Sharp, C. The Columbia-Suicide Severity Rating Scale: associations between interrupted, aborted, and actual suicide attempts among adolescent inpatients. Psychiatry Res 2017; 255: 338–40.CrossRefGoogle ScholarPubMed
Akbar, MA, Khaliq, SA, Malik, NA, Shahzad, A, Tarin, SM, Chaudhry, GM. Kala pathar (paraphenylene diamine) intoxication: a study at Nishtar Hospital Multan. Nishtar Med J 2010; 2: 111–5.Google Scholar
Suliman, SM, Fadlalla, M, Nasr Mel, M, Beliela, MH, Fesseha, S, Babiker, M, et al. Poisoning with hair-dye containing paraphenylene diamine: ten years experience. Saudi J Kidney Dis Transpl 1995; 6(3): 286–9.Google ScholarPubMed
Kondle, R, Pathapati, RM, Saginela, SK, Malliboina, S, Makineed, VP. Clinical profile and outcomes of hair dye poisoning in a teaching hospital in Nellore. Int Scho Res Not 2012; 5: 624253.Google Scholar
Umair, SF, Amin, I, Urrehman, A. Hair dye poisoning: “an early intervention”. Pak J Med Sci 2018; 34(1): 230–2.CrossRefGoogle Scholar
Daga, MK, Sinha, N, Mahapatra, HS, Kumar, R, Lalmalsawma, R, Nayak, HK, et al. Paraphenylene diamine poisoning. J Indian Med Assoc 2011; 109(1): 49.Google ScholarPubMed
Chaudhary, SC, Sawlani, KK, Singh, K. Paraphenylenediamine poisoning. Niger J Clin Pract 2013; 16(2): 258–9.CrossRefGoogle ScholarPubMed
Punjani, NS. Paraphenylene diamine (hair dye) poisoning leading to critical illness neuropathy. J Neurol Disord 2014; 2: 12.Google Scholar
Bowen, DA. A case of phenylenediamine poisoning. Med Sci Law 1963; 3: 216–9.Google ScholarPubMed
Jan, A, Khan, MJ, Khan, MTH, Khan, MTM, Fatima, S. Poisons implicated in homicidal, suicidal and accidental cases in North-West Pakistan. J Ayub Med Coll Abbottabad 2016; 28(2): 308–11.Google ScholarPubMed
Gude, D, Bansal, DP, Ambegaonkar, R, Prajapati, J. Paraphenylenediamine: blackening more than just hair. J Res Med Sci. 2012; 17(6): 584–6.Google ScholarPubMed
Parkar Khan, N, Perez-Nunez, R, Shamim, N, Khan, U, Naseer, N, Feroze, A, et al. Intentional and unintentional poisoning in Pakistan: a pilot study using the Emergency Departments surveillance project. BMC Emerg Med 2015; 15: S2.CrossRefGoogle Scholar
Parkar, SR, Dawani, V, Weiss, MG. Clinical diagnostic and sociocultural dimensions of deliberate self-harm in Mumbai, India. Suicide Life Threat Behav 2006; 36(2): 223–38.CrossRefGoogle ScholarPubMed
Weinbroum, AA, Flaishon, R, Sorkine, P, Szold, O, Rudick, V. A risk-benefit assessment of flumazenil in the management of benzodiazepine overdose. Drug Safety 1997; 17(3): 181–96.CrossRefGoogle ScholarPubMed
Shalansky, SJ, Naumann, TL, Englander, FA. Effect of flumazenil on benzodiazepine-induced respiratory depression. Clin Pharm 1993; 12(7): 483–7.Google ScholarPubMed
Figure 0

Fig. 1 Geographical map of Pakistan. AJK, Azad Jammu and Kashmir; KPK, Khyber Pakhtunkhwa.

Figure 1

Table 1 Studies on commonly used agents for poisoning in Pakistan, by region

Figure 2

Table 2 Overall demographic information for included studies

Figure 3

Table 3 Demographic information of included studies by region

Figure 4

Table 4 Demographic information of included studies by agent

Figure 5

Table 5 Overview of commonly used poisons in Pakistan

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