Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2019 Oct 9;16(10):e1002905.
doi: 10.1371/journal.pmed.1002905. eCollection 2019 Oct.

Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: A systematic review and meta-analysis

Duleeka Knipe  1 , A Jess Williams  2 , Stephanie Hannam-Swain  3 , Stephanie Upton  4 , Katherine Brown  5 , Piumee Bandara  6 , Shu-Sen Chang  7 , Nav Kapur  8
Affiliations
Meta-Analysis

Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: A systematic review and meta-analysis

Duleeka Knipe et al. PLoS Med. .

Abstract

Background: Psychiatric disorders are reported to be present in 80% to 90% of suicide deaths in high-income countries (HIC), but this association is less clear in low- and middle-income countries (LMIC). There has been no previous systematic review of this issue in LMIC. The current study aims to estimate the prevalence of psychiatric morbidity in individuals with suicidal behaviour in LMIC.

Methods and findings: PubMed, PsycINFO, and EMBASE searches were conducted to identify quantitative research papers (any language) between 1990 and 2018 from LMIC that reported on the prevalence of psychiatric morbidity in suicidal behaviour. We used meta-analytic techniques to generate pooled estimates for any psychiatric disorder and specific diagnosis based on International classification of disease (ICD-10) criteria. A total of 112 studies (154 papers) from 26 LMIC (India: 25%, China: 15%, and other LMIC: 60%) were identified, including 18 non-English articles. They included 30,030 individuals with nonfatal suicidal behaviour and 4,996 individuals who had died by suicide. Of the 15 studies (5 LMIC) that scored highly on our quality assessment, prevalence estimates for psychiatric disorders ranged between 30% and 80% in suicide deaths and between 3% and 86% in those who engaged in nonfatal suicidal behaviour. There was substantial heterogeneity between study estimates. Fifty-eight percent (95% CI 46%-71%) of those who died by suicide and 45% (95% CI 30%-61%) of those who engaged in nonfatal suicidal behaviour had a psychiatric disorder. The most prevalent disorder in both fatal and nonfatal suicidal behaviour was mood disorder (25% and 21%, respectively). Schizophrenia and related disorders were identified in 8% (4%-12%) of those who died by suicide and 7% (3%-11%) of those who engaged in nonfatal suicidal behaviour. In nonfatal suicidal behaviour, anxiety disorders, and substance misuse were identified in 19% (1%-36%) and 11% (7%-16%) of individuals, respectively. This systematic review was limited by the low number of high-quality studies and restricting our searches to databases that mainly indexed English language journals.

Conclusions: Our findings suggest a possible lower prevalence of psychiatric disorders in suicidal behaviour in LMIC. We found very few high-quality studies and high levels of heterogeneity in pooled estimates of psychiatric disorder, which could reflect differing study methods or real differences. There is a clear need for more robust evidence in order for LMIC to strike the right balance between community-based and mental health focussed interventions.

PubMed Disclaimer

Conflict of interest statement

I have read the journal's policy and the authors of this manuscript have the following competing interests: NK chairs and contributes to a number of guidelines for self-harm and suicidal behaviour and sits on the main government advisory group for suicide prevention in England. NK and DK also advised the Sri Lankan Ministry of Health on their suicide prevention strategy. NK receives research funding from government and charity sources. NK does not receive industry funding or personal remuneration.

Figures

Fig 1
Fig 1. Flowchart of studies included in this review.
Includes manuscripts that are multiple reports of the same study sample. Only one instance of each study population is retained and included in the analysis. LMIC, low- and middle-income countries.
Fig 2
Fig 2. Overall prevalence of psychiatric disorder in high versus low/moderate quality studies of fatal suicidal behaviour.
ES, Effect size.
Fig 3
Fig 3. Overall prevalence of psychiatric disorder in high versus low/moderate quality studies of nonfatal suicidal behaviour.
ES, Effect size.
See this image and copyright information in PMC

References

    1. World Health Organisation. Preventing suicide—A global imperative Geneva: WHO, 2014.
    1. Gunnell D, Lewis G. Studying suicide from the life course perspective: implications for prevention. Br J Psychiatry. 2005;187:206–8. 10.1192/bjp.187.3.206 . - DOI - PubMed
    1. Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy studies of suicide: a systematic review. Psychol Med. 2003;33(3):395–405. 10.1017/s0033291702006943 . - DOI - PubMed
    1. Cho SE, Na KS, Cho SJ, Im JS, Kang SG. Geographical and temporal variations in the prevalence of mental disorders in suicide: Systematic review and meta-analysis. J Affect Disord. 2016;190:704–13. Epub 2015/11/26. 10.1016/j.jad.2015.11.008 . - DOI - PubMed
    1. Arsenault-Lapierre G, Kim C, Turecki G. Psychiatric diagnoses in 3275 suicides: a meta-analysis. BMC Psychiatry. 2004;4:37 Epub 2004/11/06. 10.1186/1471-244X-4-37 - DOI - PMC - PubMed

Publication types