Discussion

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:

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 Pervez102–Reference 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 Haleem106–Reference 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 Nazik110–Reference 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 Ahmed114–Reference 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 Chauhan124–Reference 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 Turgut139–Reference 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.