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IntroductionSuicide is a major global public health problem. Low-income and middle-income countries contribute 78% of all suicidal deaths. Pakistan, a South Asian country, lacks official statistics on suicides at national level. Statistics on suicide are neither collected nationally nor published in the annual national morbidity and mortality surveys. Medicolegal reports on suicides and self-harm are extremely rich and important source of information but greatly underused in Pakistan. We aim to examine the patterns of suicides and self-harm retrospectively in patients who were registered with medicolegal centres (MLCs) in Karachi, during the period January 2017 to December 2021.Methods and analysisUsing retrospective descriptive design, the data will be collected from the medical records maintained at the main office of the Karachi police surgeon. Data from all nine MLCs of Karachi are collated and stored at the main office of Police surgeon. Information on suicide and self-harm cases will be extracted from records of all MLCs. The data will be collected using structured proforma and it will be analysed using descriptive and inferential analysis.Ethics and disseminationThe study was approved for exemption from Aga Khan University, Ethical Review Committee. The findings of the study will be disseminated by conducting seminars for healthcare professionals and stakeholders including psychiatrists, psychologists, counsellors, medicolegal officers, police surgeons, mental health nurses, general and public health physicians and policy makers. Findings will be published in local and international peer-reviewed scientific journals.

Made available in DSpace on 2022-04-28T19:40:08Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-07-01 Background: The COVID-19 pandemic is having profound mental health consequences for many people. Concerns have been expressed that, at their most extreme, these consequences could manifest as increased suicide rates. We aimed to assess the early effect of the COVID-19 pandemic on suicide rates around the world. Methods: We sourced real-time suicide data from countries or areas within countries through a systematic internet search and recourse to our networks and the published literature. Between Sept 1 and Nov 1, 2020, we searched the official websites of these countries’ ministries of health, police agencies, and government-run statistics agencies or equivalents, using the translated search terms “suicide” and “cause of death”, before broadening the search in an attempt to identify data through other public sources. Data were included from a given country or area if they came from an official government source and were available at a monthly level from at least Jan 1, 2019, to July 31, 2020. Our internet searches were restricted to countries with more than 3 million residents for pragmatic reasons, but we relaxed this rule for countries identified through the literature and our networks. Areas within countries could also be included with populations of less than 3 million. We used an interrupted time-series analysis to model the trend in monthly suicides before COVID-19 (from at least Jan 1, 2019, to March 31, 2020) in each country or area within a country, comparing the expected number of suicides derived from the model with the observed number of suicides in the early months of the pandemic (from April 1 to July 31, 2020, in the primary analysis). Findings: We sourced data from 21 countries (16 high-income and five upper-middle-income countries), including whole-country data in ten countries and data for various areas in 11 countries). Rate ratios (RRs) and 95% CIs based on the observed versus expected numbers of suicides showed no evidence of a significant increase in risk of suicide since the pandemic began in any country or area. There was statistical evidence of a decrease in suicide compared with the expected number in 12 countries or areas: New South Wales, Australia (RR 0·81 [95% CI 0·72–0·91]); Alberta, Canada (0·80 [0·68–0·93]); British Columbia, Canada (0·76 [0·66–0·87]); Chile (0·85 [0·78–0·94]); Leipzig, Germany (0·49 [0·32–0·74]); Japan (0·94 [0·91–0·96]); New Zealand (0·79 [0·68–0·91]); South Korea (0·94 [0·92–0·97]); California, USA (0·90 [0·85–0·95]); Illinois (Cook County), USA (0·79 [0·67–0·93]); Texas (four counties), USA (0·82 [0·68–0·98]); and Ecuador (0·74 [0·67–0·82]). Interpretation: This is the first study to examine suicides occurring in the context of the COVID-19 pandemic in multiple countries. In high-income and upper-middle-income countries, suicide numbers have remained largely unchanged or declined in the early months of the pandemic compared with the expected levels based on the pre-pandemic period. We need to remain vigilant and be poised to respond if the situation changes as the longer-term mental health and economic effects of the pandemic unfold. Funding: None. Centre for Mental Health Melbourne School of Population and Global Health University of Melbourne Swansea University Medical School Translational Health Research Institute Western Sydney University Ministry of Public Health Department of Health Promotion National Confidential Inquiry into Suicide and Safety in Mental Health University of Manchester Centre for Mental Health and Safety and National Institute for Health Research Patient Safety Translational Research Centre University of Manchester School of Public Health National Suicide Research Foundation University College Cork Australian Institute for Suicide Research and Prevention School of Applied Psychology Griffith University Institute for Life Course Health Research Department of Global Health Stellenbosch University Working Group on Prevention of Suicide and Depression at Public Health Council Department of Psychiatry Blekinge Hospital Botucatu Medical School Universidade Estadual Paulista Instituto Nacional de Psiquiatría Ramon de la Fuente Muñiz University of Rochester Medical Center Region Friuli Venezia Giulia Central Health Directorate Outpatient and Inpatient Care Service Department of Medicine University of Udine Institute of Health Behaviors and Community Sciences College of Public Health National Taiwan University Thames Valley Local Criminal Justice Board Department of Psychiatry Psychotherapy and Psychosomatics Medical University of Innsbruck Center for Outcomes Research and Evaluation Yale School of Medicine Coroners Court of Victoria Danish Research Institute for Suicide Prevention Department of Mental Health Johns Hopkins School of Public Health Centre for Mental Health Research Australian National University Brigham and Women's Hospital Department of Emergency Medicine School of Population Health University of Auckland Magistrates Court of Tasmania (Coronial Division) Bureau of Vital Records and Statistics Louisiana Office of Public Health Ministry of Public Health Undersecretary of Health Services Research Department, 113 Suicide Prevention Departments of Psychiatry and Epidemiology Columbia University Medical Center/New York State Psychiatric Institute Centre for Suicide Research University of Oxford Louisiana Department of Health Greater Manchester Mental Health NHS Foundation Trust Department of Psychiatry Aga Khan University KU Leuven Center for Contextual Psychiatry Population Health Sciences Bristol Medical School University of Bristol South Asian Clinical Toxicology Research Collaboration Faculty of Medicine University of Peradeniya World Health Organization Country Office for Nepal Karolinska Institutet Bekhterev National Medical Research Center of Psychiatry and Neurology Pavlov First Saint Petersburg State Medical University Unit Suicide Research and Mental Health Promotion Department of Social and Preventive Medicine Center for Public Health Medical University of Vienna Department of Child and Adolescent Psychiatry Medical University of Vienna School of Psychology University of Nottingham Self-Harm Research Group School of Psychology University of Nottingham Mental Health Centre Copenhagen Department of Psychiatry and Psychotherapy Klinikum Klagenfurt am Wörthersee Suicidal Behaviour Research Lab University of Glasgow Preventing Deaths from Poisoning Research Group University of Edinburgh Usher Institute University of Edinburgh Suicide Research and Prevention Center Shanghai Mental Health Center Shanghai Jiao Tong University School of Medicine Departments of Psychiatry and Epidemiology Columbia University Department of Child and Adolescent Psychiatry and Psychotherapy University of Ulm Psychosocial Services in Vienna National Centre for Suicide Research and Prevention Institute of Clinical Medicine University of Oslo Department of Child and Adolescent Psychiatry Psychotherapy and Psychosomatics University Hospital Leipzig Department of Psychiatry and Psychotherapeutic Medicine Landeskrankenhaus Villach Department of Psychiatry Psychosomatic Medicine and Psychotherapy University Hospital Frankfurt Department of Borderline Disorders and Psychotherapy Bekhterev National Medical Research Center of Psychiatry and Neurology Saint Petersburg State University Department of Psychiatry Health Authority Frankfurt am Main Department of Addictive Disorders Psychiatry and Psychotherapy LVR-Klinik Köln Department of Psychiatry Psychosomatic Medicine and Psychotherapy Goethe-University Organizational-Scientific Department Bekhterev National Medical Research Center of Psychiatry and Neurology Department of Psychiatry University of Toronto Department of Psychiatry Sunnybrook Health Sciences Centre Waseda University Faculty of Political Science and Economics Sneha—Suicide Prevention Centre Voluntary Health Services Department of Community Medicine Faculty of Medicine and Allied Sciences Rajarata University of Sri Lanka Department of Psychiatry Sackler School of Medicine Tel Aviv University and Geha Mental Health Center Division of Molecular Imaging and Neuropathology New York State Psychiatric Institute and Department of Psychiatry Columbia University National Institute of Health Research Biomedical Research Centre University Hospitals Bristol and Weston NHS Foundation Trust University of Bristol Department for Psychiatry University Psychiatric Hospital Vrapče School of Medicine University of Zagreb Botucatu Medical School Universidade Estadual Paulista

The study aimed to assess knowledge, attitudes and practices of Emergency Department staff towards patients with suicidal behaviors at a tertiary care hospital in Karachi Pakistan. An online survey found that majority of respondents were unaware of the law regarding suicide and self-harm (SH) in Pakistan. Majority had not received any specific training in management of suicidal patients. About 50 % of doctors and 16 % of nurses felt that SH patients are treated 'less seriously than patients with medical problems.' Institutional policy on management and pathway to care for suicidal patients should be disseminated and monitored for its implications in clinical practice.

Background: Despite scientific literature and media reports of rising cases of suicide and attempted suicide in different parts of Pakistan, the extent of this problem remains unknown, particularly from outside the main urban centres of the country. Aims: To report data on Suicidal Behaviour (SB) from Malakand Division, a rural and marginalised part of Khyber Pakhtunkhwa (KPK) province, explore aetiological factors and propose preventive strategies. Methods: This study followed an explanatory, mixed-method study design. The first part quantitative [QUANT] comprised of police reports on suicidal behaviour, from 2001 till first 8 months of 2018. Detailed analysis of only data from 2013 was undertaken, as data prior to 2013 contained insufficient information. The second part that is, qualitative (QUAL) consisted of in-depth interviews with relevant stakeholders. A mixed method of inductive and deductive analytical approach was used. Results: From 2013 until the first quarter of 2018, the police recorded 1,645 attempts of both males and females of which 144 (8.75%) resulted in fatalities. Suicide attempts rose by 83.4% over the 5 years and 8 months. Approximately, 43.3% of the attempts were attributed to ‘depression’. Domestic abuse was reported in 49.6% of cases. Of the total victims, 1,049 (63.7%) were females, whereas 60.1% were married. Ingestion of the organophosphates poison (pesticide) was reported in 53.2% ( n = 999) of suicide attempts. In more than 90% of the non-fatal suicide attempts, victims were booked under punitive laws. Poor socio-economic status, inter-personal stressors, violence against women and mental illnesses were the major causes of suicidal behaviour in Malakand [QUAL]. Investment in human development, strengthening of the healthcare system, de-stigmatisation of mental illnesses and women empowerment could possibly prevent suicidal behaviour in Malakand [QUAL]. Conclusion: SB in Malakand Division is steadily increasing. The increase is more evident in vulnerable populations such as women and the younger population. ‘Psychosocial stressors’ and ‘depression’ were the main causes of suicidal behaviour. A broad-based, proactive, multi-sectorial approach is needed to prevent SB in the region.

Abstract. Background: Media reporting of suicide events has thus far gone without sufficient scrutiny in Bangladesh. Aim: The purpose of this study was to assess the quality of newspaper reporting of suicides in Bangladesh against international guidelines. Methods: We used content analysis to assess the quality of suicide reporting in six daily newspapers in Bangladesh. The newspapers were hand-searched between November 2016 and April 2017 and 327 articles reporting on suicide deaths were retrieved. Results: The mean number of suicide articles per day per newspaper was 0.3 (range across newspapers 0.11–0.70) and the mean length was 11.3 sentences. Harmful reporting practices were very common (for example, a detailed suicide method was reported in 75.5% of articles) while almost no potentially helpful reporting practices were observed (for example, no articles gave contact details for a suicide support service). Limitations: The findings are limited to print mass media. Conclusions: We observed that explicit and simplistic reports of suicide deaths were frequently observed in newspapers in Bangladesh. Attempts should be made to understand the perspectives of media professionals in relation to suicide reporting, and to devise strategies to boost the positive contribution that media can make to suicide prevention in this context.

Deliberate self-harm is not only a major global public health problem but also an important index of psychological distress and a risk factor for suicide.We aimed to determine the psychosocial risk factors for deliberate self-harm in patients aged ≥ 16 years presenting to tertiary care hospitals in Kabul, Afghanistan.A matched case-control study was conducted from February 2015 to May 2015. We recruited 185 cases (patients with deliberate self-harm) and 555 age- and sex-matched controls (patients with general medical conditions) from 4 tertiary care hospitals in Kabul. We developed a questionnaire to record the sociodemographic characteristics of the participants, history of domestic violence, drug abuse and details about the act of deliberate self-harm, including the methods used. To assess depression and anxiety, we used the WHO self-reporting questionnaire (SRQ-20). Matched odds ratios with 95% confidence interval using conditional logistic regression were used to determine statistically significant associations between psychosocial factors and deliberate self-harm.Family conflicts, domestic violence, interpersonal arguments and living in extended families were found to be significantly associated with deliberate self-harm.In Afghanistan, deliberate self-harm appears to be predominately related to interpersonal problems and family conflicts. About two-thirds of females and more than half of males scored positive for depression, yet none were receiving treatment for this. These findings have important policy implications for mental health and suicide prevention programmes in the country.العوامل النفسية الاجتماعية لإيذاء الذات المُتعمد في كابول بأفغانستان: دراسة للحالات والشواهد المتوافقة في المستشفيات.أكبر بيمان، مراد خان، تازين علي، نرجس أسد، إقبال عزام.تعمُّد إيذاء الذات ليس مشكلة كبرى من مشكلات الصحة العامة العالمية فحسب، بل هو أيضاً مؤشر مهم للضائقة النفسية وعامل من عوامل الخطر التي تُفضي إلى الانتحار.تمثل هدفنا في تحديد عوامل الخطر النفسية الاجتماعية التي تُفضي إلى إيذاء الذات المُتعمَّد لدى مرضى يبلغون من العمر 16 عاماً أو أكثر ويتلقون العلاج في مستشفيات الرعاية التخصصية في كابول بأفغانستان.أُجريت دراسة للحالات والشواهد المتوافقة ابتداءً من فبراير/شباط 2015 حتى مايو/أيار 2015. واستعنّا بمائة وخمسة وثمانين حالة (مرضى الإيذاء الذاتي المتعمد) و555 حالة شاهدة متوافقة من حيث السن والجنس (مرضى يعانون من حالات طبية عامة) من أربعة من مستشفيات الرعاية التخصصية في كابول. لقد صممنا استبياناً لتسجيل الخصائص الاجتماعية والسكانية للمشاركين، تاريخ التعرُّض للعنف المنزلي، تعاطي المخدرات، تفاصيل حول "تعمد إيذاء الذات"، بما في ذلك الطرق المستخدمة لذلك. ولتقييم الاكتئاب والقلق، استخدمنا استبيان منظمة الصحة العالمية (SRQ–20)، ذاتي الإبلاغ. واستُخدم الانحدار اللوجستي المشروط بنسب أرجحية متوافقة وبفاصل ثقة قدره 95٪ لتحديد العلاقات ذات الدلالة الإحصائية التي تربط بين العوامل النفسية الاجتماعية وإيذاء الذات المتعمد.تبيَّ أن تعمُّد إيذاء الذات يرتبط ارتباطاً وثيقاً بالخلافات الأسرية، والعنف المنزلي، والسجالات المتبادلة بين الأشخاص، والعيش في أسر مفككة.يبدو في أفغانستان أن تعمُّد إيذاء الذات يرتبط في الغالب بالخلافات الأسرية ومشكلات العلاقات الاجتماعية مع الآخرين. فقد تبين أن نحو ثلثي الإناث وأكثر من نصف الذكور مصابون بالاكتئاب، ولكن لم يكن أي منهم يتلقى علاجاً لذلك. ولهذه النتائج انعكاسات مهمة على سياسات برامج الصحة النفسية والوقاية من الانتحار في البلد.Facteurs psychosociaux du comportement auto-agressif, en Afghanistan : étude avec cas et témoins appariés en milieu hospitalier.Le comportement auto-agressif est non seulement un problème de santé publique mondial majeur, mais aussi un signe manifeste de détresse psychosociale et un facteur de risque de suicide.L’objectif de la présente étude était de déterminer les facteurs de risques psychosociaux du comportement auto-agressif chez des patients âgés de 16 ans et plus en consultation au sein de centres hospitaliers de soins tertiaires à Kaboul (Afghanistan).Une étude avec cas et témoins appariés a été menée de février à mai 2015. Nous avons recruté 185 cas (patients atteints de comportement auto-agressif) et 555 témoins appariés selon l’âge et le sexe (patients atteints d’autres affections générales) consultant dans quatre centres hospitaliers de soins tertiaires à Kaboul. Nous avons mis au point un questionnaire pour enregistrer les caractéristiques sociodémographiques des participants, les antécédents de violence domestique, la toxicomanie et des détails sur le comportement auto-agressif, y compris les méthodes utilisées. Pour évaluer la dépression et l’anxiété, nous avons utilisé le questionnaire d’auto-évaluation de l’OMS (SRQ-20). Des odds ratios appariés assortis d’intervalles de confiance à 95 % obtenus par la régression logistique conditionnelle ont été utilisés afin de déterminer des associations statistiquement significatives entre les facteurs psychosociaux et le comportement auto-agressif.Les conflits familiaux, la violence domestique, les différends interpersonnels et la vie au sein de familles élargies se sont révélés être associés de manière significative au comportement auto-agressif.En Afghanistan, le comportement auto-agressif semble être principalement lié à des problèmes interpersonnels, ainsi qu’à des conflits familiaux. Près de deux tiers des femmes et plus de la moitié des hommes avaient un score positif pour la dépression ; pourtant, aucun n’était en traitement pour cette affection. Ces résultats ont des incidences politiques importantes sur les programmes de santé mentale et de prévention du suicide au sein du pays.

In the winter of 2014, four terrorists attacked a school in Khyber Pakhtunkhwa (KPK), resulting in more than a hundred students’ death. Twenty-two survivors (aged 10–18 years) with physical injurie...

In developing countries such as Pakistan, bioethics has not been included in mainstream thinking in medical education. The authors’ experiences suggest that current methods of teaching bioethics are problematic as students are unable to translate theory to practice. Alternative pedagogies, such as just-in-time learning (JiTL) using mobile devices, may be able to foster the development and implementation of ethical reasoning among nurses, doctors, and medical and nursing students. This research was conceived to determine the effectiveness of mobile JiTL – anytime, anyplace learning through mobile devices – for teaching bioethics. After obtaining ethical clearance, a participatory design (PD) approach was adopted to ensure input from all stakeholders for the design of ‘EthAKUL’, comprising a mobile app, five modules and just-in-time pedagogy. The name of the app is an acronym evoking ethics, learning and the university where the project originated. As a part of the design process, three PD workshops were held with junior doctors, nurses, nursing students, medical students and bioethics teaching faculty, and five meetings were held with faculty members, to discuss functional specifications and user-acceptance testing of the app. The feedback related to the nature of common ethical issues encountered in clinical settings, the existing process of teaching and learning bioethics, and the requested features of the app were recorded. These data sets were analyzed and synthesized into functional and technical specifications for the mobile app. The software programmers developed the app with the close involvement of the stakeholders. The development of teaching content continued alongside this process. While this enabled EthAKUL’s developers to incorporate needs of all stakeholders, challenges were encountered in the process relating to the pragmatic and conceptual aspects of JiTL, ML and PD. We discuss the implications of this research in bringing about transformative changes in higher education. How to cite this article: NASEEM, Azra; GHIAS, Kulsoom; BAWANI, Sohail; SHAHAB, Mohammad Ali; NIZAMUDDIN, Sameer; KASHIF, Waqar; KHAN, Kausar S; AHMAD, Tashfeen; KHAN, Murad. Designing EthAKUL: a mobile just-in-time learning environment for bioethics in Pakistan. Scholarship of Teaching and Learning in the South. v. 3, n. 1, p. 36-56, Apr. 2019. Available at: https://sotl-south-journal.net/?journal=sotls&page=article&op=view&path%5B%5D=70&path%5B%5D=40 This work is licensed under the Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Background Suicide and risk factors have been poorly studied in the Muslim-majority countries that hinder the formulation of prevention strategies and affect suicide prevention eventually. Objectives We aimed at identifying and analyzing the psychological autopsy studies assessing the risk factors for suicide conducted in Muslim-majority countries. Methods We did a search to trace all the available psychological autopsy studies in the Muslim countries with the search term "psychological autopsy study in Muslim countries." We also checked the available bibliographies to identify the psychological autopsy studies in the Muslim countries so that all the possible studies could be included. Results Out of the Muslim countries, only eight psychological autopsy studies were identified in five countries (Bangladesh [1], Indonesia [1], Iran [1], Pakistan [2], and Turkey [3]). Six studies adopted a case-control study design, and all were carried out in urban settings. The prevalence of psychiatric disorders among case-control studies varied from 52.8% in Turkey to 96% in Pakistan. Psychiatric illness, self-harm, and stressful life events were the commonly replicated risk factors for suicide across studies. Conclusions Psychological autopsy studies have been conducted only in five Muslim countries revealing that the risk factor for suicide is certainly under-researched in the incumbent countries. This review identified a similar list of risk factors for suicide, namely, psychiatric disorder, past non-fatal attempts, and adverse life events compared to the Western countries even though the rate varies.

Background: Suicide is a global preventable public health problem. About a quarter of all suicides in the world occur in South Asia. As means restriction is an important suicide prevention strategy, gaining knowledge of the common suicide methods and their changing trends in each country and region is crucial. Aims: We aimed to assess the suicide methods in South Asian countries over the last two decades. Methods: A search was performed in PubMed, PubMed Central, Scopus, and Google Scholar with the search terms. Original articles of quantitative studies, published in the English language, from 2001 to 2020, with full-accessible text, that rank different methods of suicide in eight South Asian countries, were included. Results: A total of 68 studies were found eligible for review. The Maximum number of studies were found from India ( n = 38), followed by Bangladesh ( n = 12), Pakistan ( n = 9), Sri Lanka ( n = 6), and Nepal ( n = 3). Hanging ( n = 40, 55.8%) and poisoning ( n = 24, 35.3%) were the two most common suicide methods reported, in that order. Hanging followed by poisoning were the commonest suicide methods in Bangladesh, India, and Pakistan while in Sri Lanka, poisoning was the preferred method to hanging. There is a decline in suicide by poisoning and an increase in suicide by hanging in Sri Lanka, Bangladesh, and India. Although hanging is still the commonest method in Pakistan, the use of firearms is growing in recent years (2011–2020). Conclusions: There is a steady decline in the incidence of suicides by poisoning following pesticide regulations in South Asian countries. However, there is heterogeneity of study methods, probable under-reporting of suicide, and lack of robust suicide data.

Background In Pakistan, the slow pace of declining fertility rate accounts for troubling consequences like multiple pregnancies, induced abortions, the low 34% contraceptive prevalence rate, and overpopulation. This coupled with the lack of literature on this topic in the country makes it pivotal to explore the gender roles and responsibilities of adults in marital life and within the family and their influence on Family Planning decisions in adults, in Karachi, Pakistan. Methods The study design involved purposive selection of 12 consenting married adults belonging to Gulberg Town, from whom detailed qualitative data was collected using open-ended, semi-structured interviews, supported by field notes. For the sake of anonymity, participants were assigned codes. Furthermore, all discussions were conducted in English or Urdu language by the female investigator herself and were audio recorded after obtaining participants’ consent. Thereafter, a rigorous thematic analysis of the interviews was carried out, with the results being double-checked before being securely stored in soft or hard copy. Results The study observations identified that gender roles and responsibilities do affect Family Planning decisions in Pakistan. The results were broadly categorized into two themes: superficial reasons and deeper reasons affecting FP decisions. The first theme has three main categories; interpretation of FP, awareness about FP, and couple as representative of FP decision making whereas the second theme has five categories; roles and responsibilities of men in the family, roles and responsibilities of women in the family, women autonomy, mind the gap or taming the women, and way forward. Conclusions Our study findings suggest that while superficial reasons must be resolved, it is primarily crucial to eliminate the subtler, tap root factors influencing FP decisions by strongly addressing school curricula, nurses, and other Health Care Workers (HCWs) to positively impact the society. Further qualitative and quantitative research is ultimately necessary for assessing the viewpoint of important stakeholders and how, using a multiprong approach, the stringent perceptions pertaining to Family Planning can be altered to benefit the society.

Background Research on suicidality in low to middle-income countries is scarce. We addressed this issue by investigating suicidality in a cross-national college student samples from 11 predominantly low to middle-income majority Muslim countries. Methods The sample consisted of 7427 college students (56% female) who reported to be affiliated with Islam. Data on self-construal, social support, negative life-events, acceptability of suicide, suicidal ideation, and suicide attempts were collected with self-administered questionnaires. Results Acceptability of suicide and the experience of negative life-events were positively, and perceived social support was negatively associated with suicidal ideation. Interdependent self-construal was negatively related to the acceptability of suicide and positively associated with perceived social support, implying a negative indirect effect on suicidal ideation although its direct effect was positive. The number of negative life-events was the strongest positive predictor of ever attempting suicide. The interdependent self-construal moderated the association of negative life-events with suicide attempts. Limitations Cross-sectional and self-report nature of the study were its major limitations. Participants may have suppressed their responses about suicide because of religious and legal reasons. Conclusion Remarkable similarities across 11 country samples emerged in the linkages between cultural and interpersonal factors with suicidality. Our findings highlight the value of a nuanced approach to suicidality, that can recognize the differences in the processes associated with suicidal ideation and suicide attempts, as well as the need to consider the interplay of a broad range of personal, interpersonal, and cultural influences.

Abstract. The WHO Eastern Mediterranean Region (EMR) consists of 22 countries including Afghanistan, Bahrain, Djibouti, Egypt, Iraq, Islamic Republic of Iran, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates (UAE), and Yemen. According to Global Burden of Disease (GBD) data, death from self-harm has increased by 100% between 1990 and 2015 in this region. Although this increase is substantial, it appears trivial in comparison to the 1027% increase in deaths due to war and legal interventions. This might partly explain why suicide prevention does not have a high priority in these countries and why there are currently no suicide prevention strategies in place. Despite the above, some important activities in the area of suicide prevention have been carried out in the region. And while peace and stability may take time to come to the region, it should not prevent suicide prevention programs from being developed and implemented.

There is a scarcity of research on suicidal phenomena in the Muslim world. Therefore, this study aimed at investigating the self-reported prevalence of suicidal thoughts, attempts and motives in 12 Muslim countries. A total of 8417 (54.4% women) university students were surveyed by means of a self-report questionnaire. Overall, 22% of the participants reported suicidal ideation and 8.6% reported attempting suicide. The odds of suicidal thoughts were elevated in Azerbaijan, Indonesia and Saudi Arabia, while reduced ORs were recorded in Egypt, Jordan, Lebanon and Malaysia. While odds of suicide attempts were high in Azerbaijan, Palestine and Saudi Arabia reduced odds ratios (OR) were detected in Indonesia, Iran, Jordan, Lebanon, Malaysia and Tunisia. Taking drugs and using a sharp instrument were the two most frequently used methods to attempt suicide. Only 32.7% of attempts required medical attention. Escape motives were endorsed more than social motives by participants who attempted suicide. Suicidal behaviors were more frequent in women than in men. Compered to men, fewer attempts by women required medical attention. Moreover, our results show that making suicide illegal does not reduce the frequency of suicidal behavior. Results from this comparative study show that suicidal thoughts and attempts are frequent events in young adults in countries where religious scripture explicitly prohibit suicide and the frequencies of nonfatal suicidal behavior show large variation in nations adhering to the same religion.

Background In Pakistan, there is high prevalence of mental health disorders, but mental health services to address these are not well developed. To provide effective mental health services, the World Health Organization emphasizes the integration of mental health into primary health care (PHC). Objectives This study aimed to assess the views of key stakeholders about integration of mental health into PHC in Karachi, Pakistan. Methods A qualitative, exploratory study was conducted between June and September 2013 among 15 decision-making (from the Department of Health) and implementation-level stakeholders (mental health and public health professionals and primary care staff) from both the public and private sectors. Face-to-face, in-depth interviews were conducted using a semi-structured interview guide. Data were collected until theoretical saturation was achieved and conventional content analysis was carried out. Results Although there was general support among all the stakeholders for integration of mental health services within PHC, there were also a number of reservations. First was the perceived lack of support within the system in terms of resource allocation and acceptance from the community. Second was the lack of human resources in the field of mental health. In addition, resistance at the PHC level is likely as staff are already burdened with other preventive care services. Conclusions The study suggests that strong political commitment, adequate human and financial resources, and strong advocacy are needed for the integration of mental health into PHC in Pakistan.

The recent controversy surrounding the National Health Service (NHS) International Fellowship Programme (IFP) for consultant psychiatrists (Patel, 2003) has raised a number of important issues. In particular, the issue of recruiting in an under-resourced developing country, where skilled and trained professionals are in short supply but where demand is huge, has exposed the duplicity with which many developed countries interact with developing countries. Although countries such as the UK are forever talking about strengthening the research and training capacity of these countries, they have no qualms about taking trained professionals for their own needs (Goldberg, 2003). Holsgrove (2005) has defended the IFP and tried to counter many of the arguments raised by those opposing it (Patel, 2003; Khan, 2004; Ndeiti et al, 2004).

At 8.52 a.m. on 8 October 2005 an earthquake measuring 7.6 on the Richter scale struck the northern part of Pakistan and devastated large areas of North West Frontier Province and Azad Kashmir. Almost 90 000 people died and many thousands were reported missing. Half the dead were estimated to be children, killed in their classrooms. Some 3.5 million people were rendered homeless. The mountainous terrain made relief work a logistical nightmare.

Aims and methods Our study investigated the pattern of referrals made to psychiatric services from the general wards of Aga Khan University Hospital (AKUH). Data on all cases referred between years 2015 to 2016 was collected retrospectively from the medical records. Information included socio-demographic details, reason for referral, past psychiatric history, treatment, management suggested and outcome of referral. SPSS version 19.0 was used for data entry and analyzing. Results During the study period 1166 cases were referred for psychiatric consultations of which 995 were analyzed. The results show an almost equal distribution of females and males. Most referrals were from Internal Medicine. The most common reason for referral was behavioral problem and the most common psychiatric diagnosis made was delirium. Clinical Implications Review of the service has identified areas that need improvement such as late referrals, problems with documentation, and issues in following through with the recommended management and will help us improve the existing services.

Background Suicide is a serious global public health problem, with more than 800,000 people dying by suicide worldwide every year. 79% of suicides happen in Low and Middle-Income Countries (LMICs), where lack of national suicide prevention programs coupled with inadequate MH facilities for early identification and treatment of mental disorders add to seriousness of the problems. Although there is paucity of research, studies suggest that the rate of suicide in district Ghizer, Gilgit-Baltistan (GB), in northern Pakistan may be higher compared to rest of the country. Methods This study aimed to explore the perceptions of stakeholders about the role of the health system at District Ghizer, GB using a qualitative descriptive exploratory research design. A total of 12 face to face in-depth interviews were conducted from the stakeholders using purposive sampling technique. Results The study results led to three broad themes, 1) Suicide as A Social Issue, 2) Role of Health System in Suicide Prevention, and 3) Challenges for Health System in Suicide Prevention. Theme one was sub-categorized into; a) Perceived situations contributing to suicide, b) Environmental factors. Theme two was subdivided into; a) Major hurdles for Health system, b) Lack of MH services in the available health system. Theme three was subdivided into; a) Lack of collaboration across-sectors, b) Unavailability of MH professionals, and c) Financial issues. The study findings reveal that there are multiple challenges for health system including, lack of awareness on mental issues, shortage of resources and lack of collaboration in the community. Moreover, existing policies or strategies need to be modified to overcome the existing challenges for the effective prevention. Conclusion This study emphasized creating awareness about MH issues, introduction of school health programs, parental counseling session and strengthening of the health system by allocating suitable budget for MH issues and suicide prevention strategies.

Background Suicide and deliberate self-harm (DSH) are major public health problems globally. There is limited information on suicide and DSH from Afghanistan. Aims To review available literature on suicide and DSH in Afghanistan. Methods Using online resources and literature on suicidal behavior (suicide, DSH and suicidal ideation) was searched. Results There were only seven published studies identified on suicidal behavior in Afghanistan. Six of these have been published since 2003 and majority has focused on suicidal behavior in women. Conclusions Both DSH and suicide are underreported and understudied subjects in Afghanistan. There is need for more research in this area.

Objective The study investigated the associations of religiosity, religious coping and suicide acceptance to suicide ideation and attempts in 7427 young adults affiliating with Islam from 11 Muslim countries. Method A self-administered questionnaire was used to collect the data. We used F and χ2 tests and correlation analyses to report descriptive statistics. Multi-group path models with (i) a zero-inflated Poisson distribution and, (ii) a Binomial distribution were used to model the number of occurrences of suicidal ideation, and occurrence of a suicide attempt, respectively. Results Religiosity was negatively associated with acceptability of suicide, but it was positively related to punishment after death across the 11 countries. Religiosity was negatively associated with ever experiencing suicidal ideation, both directly and indirectly through its association with attitudes towards suicide, especially the belief in acceptability of suicide. Neither positive nor negative religious coping were related to suicidal ideation. However, religiosity was negatively related to suicide attempts among those who experienced suicidal ideation at least once. This association was mediated through the belief in acceptability of suicide and religious coping. Negative religious coping was positively associated with suicide attempts probably because it weakened the protective effects of religiosity. Conclusions Findings from this study suggest that the effects of religiosity in the suicidal process operate through attitudes towards suicide. We therefore conclude that clinical assessment as well as research in suicidology may benefit from paying due attention to attitudes towards suicide.

The Global Burden of Disease study shows that the burden from mental and substance use disorders, measured in Disability Adjusted Life Years (DALYs), has steadily risen in the Eastern Mediterranean Region (EMR) over the last three decades and is higher than the global average for almost all EMR countries). Even more alarming is the finding that depression, self-harm, anxiety and conduct disorders constitute four of the top 10 causes of DALYs among girls and boys aged 15-19 years and suicide is a leading cause of adolescent mortality. More than 70% of all mental disorders begin before the age of 25 years old. Risk factors for mental disorders include genetic pre-disposition, deficiencies in psychosocial or educational environments, alcohol and drug misuse, and family, peer or school problems.

Suicide is a major global public health problem with more than 800,000 incidents worldwide annually. Seventy-five percent of the global suicides occur in low and middle-income countries (LMICs). Pakistan is a LMIC where information on suicidal behavior is limited. The aim of the review is to map available literature on determinants, risk factors and other variables of suicidal behavior in Pakistan. This study was based on Arksey and O’Malley’s methodological framework of scoping review, combining peer reviewed publications with grey literature. Ten databases including Applied Social Sciences Index and Abstracts (ASSIA), Cochrane Trials Register (CRG), Cumulative Index to Nursing and Allied Health (CINAHL), National Library of Medicine Gateway (NLMG), ExcerptaMedica (EMBASE), National Library of Medicine’s MEDLINE (PUBMED), PSYCHINFO, Social Science Citation Index and Science Citation Index (SCI) and Pakmedinet.com were searched from the beginning of their time frames until December 2016 using a combination of key terms. The inclusion criteria included studies of various study designs covering different aspects of suicidal behavior in English language. Six hundred and twenty three articles were initially retrieved from all ten databases. Two independent reviewers screened the titles and abstracts for relevance. One hundred and eighteen articles were read in full, out of which 11 were excluded because they did not fit the eligibility criteria. One hundred and ten articles, including two student theses and one report, were included in the final review. Most studies were descriptive in nature, with only three that used a case-control design. Majority of the studies were from urban areas, and addressed determinants rather than risk factors. Gender differences and age were predominantly reported, with more males committing suicide. Suicidal behavior was more common among individuals younger than 30 years of age. The three most common methods for suicides were hanging, poisoning and use of firearms. Mental illness as a risk factor for suicides was mentioned in only three studies. This review is the first attempt to synthesize available literature on suicidal behavior in Pakistan. The evidence is limited, and calls for more robust analytical research designs, along with a focus on risk factors.

Background.In 2014, over a million people were internally displaced after the launch of a military operation in North Waziristan, a tribal region on Pakistan's side of the Durand Line. Despite security concerns and restrictions, a collaborative mental health and psychosocial support initiative was undertaken in the district of Bannu. Monthly mental health camps were conducted for a period of 6 months by a multidisciplinary mental health team. The initiative also helped to assess mental health needs and plan training for primary care staff to strengthen existing resources.Methods.As part of this initiative, Mental Health Gap Action Programme (mhGAP) training was conducted for physicians and psychosocial staff in the affected district. This marked the first instance of implementing these guidelines in Pakistan following a humanitarian crisis. This paper describes the training process including the adaptation of the mhGAP curriculum, training of trainers, training workshops for primary care staff and an analysis of results of pre- and post-testing of their knowledge about common mental disorders using a 25-item questionnaire.Results.The gaps in knowledge of primary care physicians in recognizing and managing common mental disorders were clearly identified. The mean pre- and post-test scores of the participants were 15.43, 62% (p value 0.000, s.d. 4.05) and 19.48, 78% (p value 0.000, s.d. 3.13) respectively, which showed significant improvement.Conclusions.Despite the challenges of a humanitarian crisis, mhGAP guidelines can be successfully implemented to train primary care physicians in in low- and middle-income countries such as Pakistan. However, the dearth of primary care resources can hinder the complete integration of mental health services into primary healthcare.

The 5-year undergraduate medical curriculum at Aga Khan University integrates basic sciences with clinical and community health sciences. Multimodal strategies of teaching and learning, with an emphasis on problem-based learning, are utilized to equip students with knowledge, skills, behaviours, attitudes and values necessary for a high-calibre medical graduate. Bioethics teaching was introduced in the medical curriculum in 1988 and has since undergone several changes. In 2009, a multidisciplinary voluntary group began review of undergraduate bioethics teaching and invested over 350 man-hours in curricular revision. This involved formulating terminal objectives, delineating specific objectives and identifying instructional methodologies and assessment strategies appropriate for the contents of each objective. Innovative strategies were specially devised to work within the time constraints of the existing medical curriculum and importantly, to increase student interest and engagement. The new bioethics curriculum is designed to be comprehensive and robust, and strives to develop graduates who, in addition to being technically skilled and competent, are well-versed in the history and philosophy of ethics and bioethics and are ethical in their thinking and practice, especially in the context of a developing country like Pakistan where health indicators are among the worst in the region, and clinical practices are not effectively regulated to ensure quality of care.

Suicide is an understudied subject in Pakistan. There are many social, legal, and religious sanctions against it. National rates of suicides are not known. We calculated suicide rates of women in the Ghizer District of the remote Northern Areas of Pakistan. During years 2000 to 2004, 49 women committed suicide. Taking average mean population for women for 5 years as 65,783, we calculated annual crude suicide rates for women as 14.89/100,000/year. For women over the age of 15 years, rates were 33.22/100,000/year; age-specific rates for 15-24 years were 61.07/100,000 per year. These figures are considerably higher than suicide rates in other parts of Pakistan and may be related to high psychiatric morbidity in Pakistani women. This study underscores the need for a standardized system of registration of suicides in Pakistan. There is also urgent need to address high psychological distress in women in Pakistan.

A multinational pharmaceutical company recently launched a drug for dementia in Pakistan and flew about 70 Pakistani doctors to Bangkok, Thailand for a 3-night all-expenses-paid trip (Khan, 2004). Pakistani doctors were part of a larger group that also included doctors from other countries. A conservative estimate of costs for the Pakistani doctors alone is about 7 million Pakistani rupees (Rs) (£70 000, US$120 000).

There are very few reports of electroconvulsive therapy (ECT) from developing countries, where lack of regulation and misuse has lead to negative publicity. We present our experience of ECT use at a university hospital in Karachi, Pakistan, over the course of 13 years. During the study period, 4013 patients were admitted to our inpatient unit, of which 136 (3.38%) received ECT. ECT was conducted under the supervision of consultant psychiatrist and anesthetist with continuous monitoring during and after the procedure. The most common indications were mood disorders. The average number of ECTs administered per patient was 6 (range, 1-20). A total of 35% of patients had medical comorbidities but did not suffer any deleterious effect from the procedure. A total of 75% patients showed improvement in their clinical condition. No major complication was observed in any of the patients. Our study demonstrates the effectiveness if ECT in a low-income, developing country. We strongly recommend following guidelines to ensure patient safety and minimizing side effects. This will ensure better patient acceptability and compliance.

The concept of marital satisfaction is an important area of research in the context of marriage and family relationships. This has not been previously examined in Pakistan, a conservative patriarchal Islamic country, where studies examining psychiatric morbidity have shown marital problems as contributing to Common Mental Disorders (CMDs). Young married women under the age of 35 years appear to have a higher prevalence of CMDs than older married women. In this pilot study, using both a quantitative and a qualitative approach, we examined the construct of marital satisfaction and tested the applicability of marital satisfaction scales developed in the West for use in Pakistan. The results indicate that, contrary to cultural beliefs regarding marriage, most women expressed the need to be satisfied within marriage. The fear of hurting or annoying their parents prevented many women from openly expressing their opinion in the choice of husband or unhappiness in their marriage. Pakistani women tend to see marri...

The aim of the study was to determine the functional status and level of physical activity and their association with depression in the elderly population (age 60 and above) in Karachi, Pakistan.This was a cross-sectional study. Subjects were recruited through multi-stage cluster sampling technique. Questionnaire-based interviews were conducted from July to September 2008. Functional status and physical activity were assessed using activities of daily living (ADL) and physical activity questionnaires, respectively. Depression was evaluated using the 15-item geriatric depression scale (GDS).Both mean ADL score (9.9±0.2 vs. 9.6±0.2) as well as time spent in physical activity/week (377.3±26.9min vs. 251.7±15.4min) was higher in men than women, respectively. Subjects spending more than 310min (5.2h) per week in physical activity were 60% less likely to be depressed compared to those who spent less than 120min (2h) per week (Adjusted OR=0.4, 95% CI=0.2-0.7). A one unit increase in ADL score showed a 10% decrease in depression after adjusting for other variables (Adjusted OR=0.9, 95% CI=0.8-0.9).We found a strong association between depression and time spent in physical activities as well as activities of daily living. Our results indicate the potentially important positive role of higher functional status and physical activity in prevention of depression in the elderly in Karachi.

There is paucity of information on suicide from Pakistan, an Islamic country in which data collection poses formidable challenges. A variety of social, legal, and religious factors make reporting and diagnosing suicide difficult. Paradoxically, incidents of suicide are regularly reported in newspapers in Pakistan. In the absence of other means these reports serve a useful, though basic information source for suicidal deaths. A 2-year analysis of all such reports in a major newspaper in Pakistan showed 306 suicides reported from 35 cities. Men (n = 208) outnumbered women by 2:1. While there were more single than married men, the trend was reversed in women. The majority of subjects were under 30 years of age and “domestic problems” was the most common reason stated. More than half the subjects used organophosphate insecticides, while psychotropics and analgesics were used infrequently. The study challenges the widely held belief that suicide is a rare phenomena in an Islamic country like Pakistan, and underscores the need for more culture specific research on this important public health problem.

Fate, it seems, conjures up all sorts of ways for us to be in a certain place at a certain time. In 1982 as a trainee psychiatrist in the UK, I found myself co-facilitating a group at the Castlewood Day Hospital, then part of the Bexley psychiatric rotation scheme, in the south-east of London. Group psychotherapy was part of our training. Held thrice a week the groups were open-ended and patients ranged from those with interpersonal relationship and personality problems to those with anxiety and substance misuse problems. At the time the experience was somewhat baffling. Not only was I from a different country and culture, my exposure to psychiatry was limited to about 12 months. More often than not I felt lost as I tried to come to terms with ‘group dynamics', ‘reality testing’, ‘transference’, ‘multiple transference’, ‘group cohesion’, ‘group pressure’, etc.

At 8.52 a.m. on 8 October 2005 an earthquake measuring 7.6 on the Richter scale struck the northern part of Pakistan and devastated large areas of North West Frontier Province and Azad Kashmir. Almost 90 000 people died and many thousands were reported missing. Half the dead were estimated to be children, killed in their classrooms. Some 3.5 million people were rendered homeless. The mountainous terrain made relief work a logistical nightmare.