Suicide rates and suicidal behaviour in displaced people: A systematic review

Abstract

Background: Refugees, and other forcibly displaced people, face mental distress and may be disproportionately affected by risk factors for suicide. Little is known about suicidal behaviour in these highly mobile populations because collecting timely, relevant, and reliable data is challenging.

Methods and findings: A systematic review was performed to identify studies of any design reporting on suicide, suicide attempts, or suicidal ideation among populations of displaced people. A sensitive electronic database search was performed in August 2020, and all retrieved studies were screened for relevance by two authors. Studies were categorised by the population being evaluated: refugees granted asylum, refugees living in temporary camps, asylum seekers, or internally displaced people. We distinguished between whether the sampling procedure in the studies was likely to be representative, or the sample examined a specific non-representative subgroup of displaced people (such as those already diagnosed with mental illness). Data on the rates of suicide or the prevalence of suicide attempts or suicidal ideation were extracted by one reviewer and verified by a second reviewer from each study and converted to common metrics. After screening 4347 articles, 87 reports of 77 unique studies were included. Of these, 53 were studies in representative samples, and 24 were based on samples of specific target populations. Most studies were conducted in high-income countries, and the most studied population subgroup was refugees granted asylum. There was substantial heterogeneity across data sources and measurement instruments utilised. Sample sizes of displaced people ranged from 33 to 196,941 in studies using general samples. Suicide rates varied considerably, from 4 to 290 per 100,000 person-years across studies. Only 8 studies were identified that compared suicide rates with the host population. The prevalence of suicide attempts ranged from 0.14% to 15.1% across all studies and varied according to the prevalence period evaluated. Suicidal ideation prevalence varied from 0.17% to 70.6% across studies. Among refugees granted asylum, there was evidence of a lower risk of suicide compared with the host population in 4 of 5 studies. In contrast, in asylum seekers there was evidence of a higher suicide risk in 2 of 3 studies, and of a higher risk of suicidal ideation among refugees living in camps in 2 of 3 studies compared to host populations.

Conclusion: While multiple studies overall have been published in the literature on this topic, the evidence base is still sparse for refugees in camps, asylum seekers, and internally displaced people. Less than half of the included studies reported on suicide or suicide attempt outcomes, with most reporting on suicidal ideation. International research networks could usefully define criteria, definitions, and study designs to help standardise and facilitate more research in this important area.

Registration: PROSPERO CRD42019137242.

Fig 1. PRISMA flow diagram.

Fig 2. Suicide in displaced people compared to host country population.

Norredam 2013 [62] adjusted for age and income; Amin 2021 [20] adjusted for socio-demographic, labour market marginalisation and morbidity factors (i.e. sex, age, educational level, family situation and type of residential area, days with full-time unemployment, net days with sickness absence, granted disability pension, history of suicide attempt; history of inpatient or specialised outpatient healthcare); Hollander 2020 [42] adjusted for attained age, gender, and disposable income; Goosen 2011 [37] standardised for age; Westman 2006 [89] adjusted for age, marital status, socioeconomic status, and hospitalization for psychiatric disorders or substance abuse; Saunders 2019 [73] and Mittendorfer-Rutz 2020 [57] were unadjusted.

Fig 3. Suicide attempts in displaced people compared to host population forest plots, grouped by outcome measure and then sub-grouped by population type.

Choi 2020 [30] adjusted for interview year; Stein 2010 [81] adjusted for person-year, country, demographic factors (age, sex, time-varying education, time-varying marriage), interactions between life course and demographic variables, parent psychopathology, and childhood adversities; Amin 2021 [20] adjusted for socio-demographic, labour market marginalisation and morbidity factors (i.e. sex, age, educational level, family situation and type of residential area, days with full-time unemployment, net days with sickness absence, granted disability pension, history of suicide attempt; history of inpatient or specialised outpatient healthcare); Sohn 2019 [77] age- and gender-matched; Marroquin-Rivera 2020 [54] unadjusted.

Fig 4. Suicidal ideation in displaced people compared to host population forest plots, grouped by outcome measure and then by population type.

Choi 2020 [30] adjusted for interview year; Stein 2010 [81] adjusted for person-year, country, demographic factors (age, sex, time-varying education, time-varying marriage), interactions between life course and demographic variables, parent psychopathology, and childhood adversities; Sohn 2019 [77] age- and gender-matched; Akinyemi 2012 [16], Itani 2017 [45], Slodnjak 2002 [75], Marroquin-Rivera 2020 [54], and Salama 2020 [71] were unadjusted.