Bangladesh is the eighth most densely populated country in the world. According to the latest census (2021), about 170 million people live in its 147 570 km2, 90% of whom are Muslims. 1 It is a lower-middle-income country in South Asia facing burdens of both communicable diseases and non-communicable disorders with limited resources. About 5% of the total budget is allocated to health and 0.5% of that is allocated to mental health.
Suicide and suicide prevention are under-prioritised in the Bangladesh. The lack of a national suicide database and suicide prevention programme, suicide’s criminal legal status, stigma, poor-quality media reporting, inadequate clinical services for suicidal behaviour, and an inadequate budget are the primary challenges for suicide prevention in the country. Reference Hoque2 Of these problems, the absence of a national database is the most important, as without data, the rate, trends, methods, gender distribution and risk factors of suicide are not known and resources cannot be effectively allocated. There are wide variations in estimates of suicide and attempted suicide rates from study to study. Reference Kabir, Hasan and Arafat3 The World Health Organization (WHO), which uses mathematical modelling to estimate national suicide rates from published data, has rated the quality of suicide data for Bangladesh as category 4 (i.e. death registration data are unavailable or unusable owing to quality issues). Reference Kabir, Hasan and Arafat3
This paper aims to discuss policy-level considerations of suicide prevention in Bangladesh in the context of current mental health legislation and policies, suicide prevention initiatives and stakeholders.
Mental health legislation and policies
Bangladesh enacted a new Mental Health Act 4 in 2018, and in 2022 it published its National Mental Health Policy (NMHP) 5 and National Mental Health Strategic Plan (NMHSP) for 2020–2030. 6
The Mental Health Act
The Mental Health Act 2018 replaced the Lunacy Act of 1912. It highlights several major issues in areas such as the establishment of mental hospitals and rehabilitation centres, hospital admission and treatment procedures, and the legal status and guardianship (of the person and property) of people with mental disorders. However, it does not include any sections on suicide and suicide prevention in Bangladesh.
The NMHP
The NMHP, published in 2022 in English and Bangla versions, includes suicide risk reduction as one of its 15 objectives. 5 It covers three major areas: (a) development of a national suicide prevention strategy, (b) raising awareness, development of emergency response measures and gatekeeper training, and (c) quality improvement in data collection and analysis to understand and prevent risk factors for suicide (as per the Bangla version).
Limitations of the NMHP
The policy considers key areas of suicide prevention. However, it pays little attention to national suicide data and fails to recognise the importance of a nationwide suicide surveillance strategy. Without quality data on suicide, suicide prevention is not possible. Furthermore, the English and Bangla versions bear different meaning: the Bangla version mentions quality improvement of data collection and analysis whereas the English version recommends that more research be conducted. 5
The National Mental Health Strategic Plan (2020–2030)
The NMHSP (2020–2030) was also published in 2022. Under general objective 3 (‘to implement strategies for mental health promotion and risk reduction for mental health conditions’) it mentions reducing the suicide mortality rate by 5% by 2025. 6 It includes four specific objectives, the third of which targets suicide risk reduction and reduction of the incidence of suicides and suicide attempts by increasing awareness and monitoring for help-seeking behaviours. This specific objective identifies several activities: research; establishment of a suicide and self-harm registry; suicide surveillance; development of national strategy on substance misuse and suicidal behaviour; decriminalisation; restriction of the means of suicide (e.g. hazardous pesticides); referral to health services; emergency services for suicide attempts; a national suicide prevention programme; gatekeeper training; a crisis helpline; postvention (supporting those bereaved by suicide); and adoption of media guidelines. 6
Limitations of the NMHSP
The NMHSP includes fairly comprehensive potential suicide prevention activities, touching on most of the components of the national strategy suggested by the WHO. 7 However, it has several limitations.
First, it misses two important components included in both the WHO strategy and the NMHP, i.e. awareness building and stigma reduction. These cannot be ignored in Bangladesh, where there is low suicide literacy and high stigma surrounding suicide. 4 The NMHSP considers awareness building in specific areas, i.e. among farmers for restricting hazardous pesticide use and among stakeholders for decriminalisation of suicide. As universal strategies, raising awareness and reducing stigma should be prioritised, in addition to supporting specific initiatives, such as decriminalisation. Reference Hoque2
Second, under the category of restriction of the means of suicide, it considers only hazardous pesticides. However, all highly hazardous pesticides (WHO toxicity class I) were banned in Bangladesh in 2000. Reference Chowdhury, Dewan, Verma, Knipe, Isha and Faiz8 It ignores drugs such as benzodiazepines, which are one of the most common self-harm methods used in suicide attempts in the country. Reference Arafat, Shormi and Kibria9
Third, it mentions a target to reduce suicide by 5% by 2025. This raises obvious questions regarding the denominator when there are no publicly available annual suicide data.
Urgent need for suicide prevention in Bangladesh
As mentioned above, Bangladesh urgently needs the establishment of a national suicide database and national surveillance to understand the rate and risk factors for suicide and suicide attempts, as well as the gender distribution, suicide trends and methods, and resource allocation. Subsequently, a national suicide prevention programme could be prioritised that would include decriminalisation and other components of the WHO national strategy and ensure their implementation. Decriminalisation is necessary to increase help-seeking in suicide attempts and other suicidal behaviour, as well as to avoid under-reporting and misclassification of suicide.
Sources of data
Police records could be an immediate source of suicide data in Bangladesh. Owing to the country’s legislative structure and the designation of suicide as a crime, suicide (as a mode of death) is decided on by police and other law enforcement agencies (Additional District Magistrates) with the help of forensic experts and chemical analysis of viscera. The police are the first responders to suspected suicide deaths. When a suspected suicide is reported to a thana (regional police station), a police officer (not below the rank of sub-inspector) visits the place and prepares the necessary procedures for a post-mortem. Reference Bose, Kushal, Arafat, Arafat and Khan10 Therefore, every thana has data on deaths determined to be suicides (including name, age, gender, method, time, place and associated factors) recorded under ‘unnatural deaths’, which have to be regularly reported to the district level (Police Super) office. As a result, police headquarters could easily record and publish annual data. However, utilisation of police data in a country where suicide is a criminal offence may have several weaknesses, including under-reporting, non-reporting and misclassification. Nevertheless, as there is a ready-made structure for suicide reporting by the police in Bangladesh, only slight modifications would make this very useful in setting up a suicide prevention programme.
Prominent stakeholders
Suicide is multifactorial and suicide prevention needs everyone’s participation with enduring collaboration among the stakeholders. However, based on the current status of suicide prevention in Bangladesh, the prominent stakeholders and their links have been discussed.
Law enforcement agencies
At present, law enforcement agencies are important stakeholders in suicide prevention. First, the police are the first responders to a suspected suicide, and they collect the field-level data that they report to the local thana. An Additional District Magistrate decides the nature of death (suicide) with help of the police (the Officer in Charge) of the local thana. If family members request that a post-mortem is not performed, the law enforcement agencies make the decision. And, suicide is finally decided by the law enforcement agency.
Second, the ‘999’ National Emergency Service telephone line, which was started on 12 December 2017 and is maintained by the Ministry of Home Affairs, is currently run by Bangladesh Police. One news story reported that in the first 4 years of its operation, it prevented around 1500 suicides. Reference Rahman11
Third, law enforcement agencies could have a significant collaborative role in crisis management teams helping people who have made suicide attempts.
The legislative body
The legislative body in Bangladesh has an important stake in suicide prevention in areas where legal status changes are warranted, i.e. decriminalisation of suicide and restricting the means of lethal self-harm, for example by banning certain pesticides and restricting access to drugs commonly used in suicide attempts, such as benzodiazepines. Decriminalisation would help to reduce stigma and remove the legal and social barrier of help-seeking for suicidal behaviour. Furthermore, most individuals who have made a suicide attempt not only become police cases but are also referred to public hospitals that are usually located far from home. Decriminalisation would reduce the suffering and might improve the attitude of mental health services to this currently neglected patient population. Additionally, decriminalisation would reduce the suffering and might improve care by lessening the stigma many mental health professionals associate with attempted suicide.
The media
The media could play a significant role in suicide prevention in several areas, such as improving the quality of media reporting, which is poor, Reference Hoque2 increasing awareness among the general population and reducing stigma.
Mental health professionals
Mental health professionals could play an important role in ensuring adequate psychosocial services for people with suicidal thoughts, those who have survived a suicide attempt, and family and others bereaved by suicide (postvention).
Public health professionals
In Bangladesh, as in the rest of the world, suicidal behaviour is multifactorial and social determinants play a significant deciding role. Thus, the global notion of a strong public health approach targeting the whole population is needed. 7,Reference Pirkis, Dandona, Silverman, Khan and Hawton12
Others
Along with the above-mentioned professional stakeholder involvement, over the course of time, the nation itself needs to think about suicide prevention, for example by expanding the availability of third-sector (volunteer run) suicide and emotional support helplines (such as Kaan Pete Roi), more widespread gatekeeper training, the involvement of the family in suicide prevention, as pre-marital, marital and extra-marital life events are an important issue in Bangladesh, and the setting up of school mental health programmes on suicide prevention.
In conclusion, this article explored the policy-level status and potential weakness of suicide prevention strategies in Bangladesh. It highlights the urgent need for improved suicide prevention in the country and suggests potential stakeholders to bring it about. A national suicide database should be the beginning of all suicide prevention initiatives. And in the long run, suicide prevention should be considered through the lens of public health.
Data availability
Data availability is not applicable to this article as no new data were created or analysed in this study.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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