Suicide prevention by empowering adolescents in Pakistan (SEPAK): A feasibility study for research capability and trial readiness in Pakistan
Close to 800 000 people die due to suicide every year, this is one person every 40 seconds. Worldwide, suicide accounts for an estimated 6% of all deaths among young people. As the second leading cause of mortality among females and the third leading cause among males aged 10–24 years, youth suicide is a major global public health concern. Low- and middle-income countries are home to more than 90% of the world’s children and youth and also account for over 79% of global suicide deaths. However, compared to high-income countries relatively little is known about the epidemiology of adolescent suicide and suicidal behaviors in low- and middle-income countries.
Pakistan is a low income country with an estimated population of 200 million, making it the 6th most populous country in the world. Approximately 50% of its population is under the age of 25 years. Prevalence rates of common mental disorders (CMDs) put the figure as high as 34%. Suicidal behaviors are an under-researched and under-studied subject in Pakistan. Official mortality statistics on suicide are not available since they are not part of the national vital registration system nor reported to the WHO. Over the last couple of decades, there have been a growing number of studies on suicide and self-harm that draw attention to the fact that suicidal behavior is being recognized as a serious public health problem in Pakistan. However, these are individual level studies that make it difficult to get a national picture of suicidal behavior. Furthermore, under-reporting and lack of research may occur due to criminalization of suicidal behavior in Pakistan. According to the Pakistan Penal Code (PPC) 325 “Whoever attempts to commit suicide and does any act towards the commission of such offence shall be punished with simple imprisonment for a term which may extend to one year, (or with fine, or with both)”.
The law itself derives from the tenants of Islam, which strongly condemns suicidal behavior. Under this law every case of suicide or self-harm must be taken to one of the city/town’s government hospitals that is officially designated as a ‘medico-legal center’ (MLC). Only the MLCs are authorized to receive cases of suicide and self-harm. In reality however, people with self-harm avoid going to the MLCs, for fear of legal complications and many seek treatment from private hospitals. Similarly, the latter, in order to protect the individual (and themselves) do not report DSH cases to the police, mislabeling them as either ‘accidental’ or give them a medical diagnosis. Also, as private medical care in Pakistan is quite expensive, many people leave against medical advice after emergency medical treatment. Therefore, due to both financial reasons as well as legal, socio-cultural and religious stigma surrounding suicidal behavior in Pakistan, the underlying psychosocial issues remain largely unaddressed. The social consequences of suicidal behavior in Pakistan can be quite significant, with families often stigmatized and ostracized. Stigmatization of suicidal behavior in Pakistani society may also be contributing to lack of research on the subject.
Considering the limited evidence available on suicidal behavior in Pakistan, Pakistan Institute of Living and Learning (PILL) vision is to create the infrastructure to undertake the largest suicide prevention trial in Pakistan. This includes developing the research to deliver a large scale cRCT, including training staff, identifying recruitment pathways, culturally adapting outcome measures and establishing a patient-public voice network. A large number of international policy strategies recommend suicide prevention approaches that operate across clinical, educational, workplace and community settings. Most adolescents attend schools and colleges, which makes these an appropriate setting for reaching young people. Although school-based suicide prevention interventions are much needed, they are sparse in high income countries and non-existent in Pakistan.
The aim of this research programme is to develop national youth suicide prevention strategy in Pakistan including the training of school teachers and healthcare professionals in screening and managing adolescents with suicidal behaviours. For this purpose universal suicide prevention strategies will be culturally adapted which includes three separate interventions (1) the Question, Persuade, and Refer (QPR), a gatekeeper training module targeting school personnel, (2) the Youth Aware of Mental Health Programme (YAM), a universal intervention which engaged adolescents in role-play sessions and interactive lectures about mental health and (3) the screening by professionals (ProfScreen) with referral of at-risk adolescents. Once the interventions will be culturally adapted an open-label feasibility study will be conducted using 12 secondary schools, targeting students (12-17 years) and teachers from these schools in low income urban areas; primary health care professionals from the hospitals near the participating schools.