https://doi.org/10.35845/kmuj.2024.23563
VIEWPOINT
Framework for suicide prevention among college students in low- and middle-income countries
Alaptagin Khan 
1,2 , Abdul Wahab Yousafzai 3 , Jason Bantjes 4,5
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1: Department of Developmental Biopsychiatry Research Program, McLean Hospital, Belmont, Massachusetts, United States of America 2: Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America 3: Department of Psychiatry, Shifa International Hospital, Shifa Tameer-e-Millat University, Islamabad, Pakistan 4: Department of Mental Health, Alcohol, Substance Use and Tobacco Unit South African Medical Research Council, Cape Town, South Africa 5: Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
Email
Contact #: +1-617-855-2096
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THIS ARTICLE MAY BE CITED AS: Khan A, Yousafzai AW, Bantjes J. Framework for suicide prevention among college students in low- and middle-income countries. Khyber Med Univ J 2024;16(3)270-73. https://doi.org/10.35845/kmuj.2024.23563 |
ABSTRACT
Suicide prevention in low- and middle-income countries (LMICs) faces unique challenges due to limited epidemiological data and contextual variations. This article highlights the urgency of addressing suicide, the second leading cause of death among individuals aged 15 to 29 globally, emphasizing the heightened vulnerability during college years. While high-income countries (HICs) have established surveillance systems, LMICs struggle due to inadequate resources, cultural stigma, and competing health priorities. The scarcity of reliable data hinders the formulation of evidence-based prevention programs and national policies.
The article advocates for the implementation of surveillance systems on university campuses, utilizing cost-effective online mental health surveys like the WHO International College Student Initiative. Understanding the etiology of suicidal behavior is crucial, with psychosocial stressors affecting both HIC and LMIC college students, but the latter facing additional challenges like gender-based violence and financial stress. Cultural nuances further necessitate qualitative research to design context-sensitive prevention interventions.
Access to mental healthcare is identified as a key preventive measure, especially on campuses, but challenges persist in encouraging help-seeking behavior. Digital interventions are proposed as promising solutions, considering their efficacy and potential to bridge treatment gaps in resource-constrained environments.
KEYWORDS:Suicide, attempted (MesH); Suicidal Ideation (MesH); Suicide Prevention (MesH); Suicide, assisted (MesH); Suicide, attempted (MesH); Suicide, completed (MesH); Developing Countries (MesH); Low- and Middle-Income Countries (Non-MesH); School Mental Health Services (MesH).
Suicide is a major public health concern, claiming approximately 800,000 lives worldwide each year.1 Rates of suicidal behaviour are particularly high among adolescents and young adults, 2,3 contributing to 6% of deaths in this age group worldwide.4 Among individuals aged 15 to 29, suicide is the fourth leading cause of death,5 with the onset of suicidal behavior typically occurring in late adolescence.6 These statistics emphasize the importance of early identification and intervention during this critical developmental period, highlighting colleges as key settings for implementing targeted suicide prevention strategies.7,8
According to Mortier et al., a study on suicidal thoughts and behaviors among first-year college students found a lifetime prevalence of 32.7% for suicidal ideation, 17.5% for suicide planning, and 4.3% for suicide attempts. The 12-month prevalence rates were 17.2% for suicidal ideation, 8.8% for planning, and 1.0% for attempts.8 Although data on the prevalence of suicidal behaviour in low- and middle-income countries (LMICs) is limited, emerging evidence suggests that rates of non-fatal suicidal behavior may be even higher than those typically reported in high-income countries (HICs).9 For instance, a study of first-year students in South Africa reported 12-month prevalence rates of 40.9% for suicidal ideation, 22.3% for suicide planning, and 3.9% for suicide attempts.10
The need for reliable epidemiological data: Reliable and timely epidemiological data are the cornerstone of evidence-based suicide prevention. However, reliable data on adolescent suicidal behavior is scarce in many countries, especially in LMICs. Several factors contribute to the lack of suicide data from LMICs, including inadequate surveillance systems, cultural factors such as stigma, legal factors like the criminalization of suicidal behavior that deter reporting, and competing health demands from infectious diseases like Human Immunodeficiency Virus, Tuberculosis, and Malaria, which make suicide prevention a lower priority for health agencies.
The shortage of accurate epidemiological data in LMICs impedes suicide prevention efforts, creating a significant barrier to establishing priorities and planning evidence-based programs. This is evident from the lack of national suicide prevention policies in many LMICS.11 Despite global evidence indicating that the college years are a high-risk period for mental health issues, there is a paucity of data on college student mental health in Pakistan, even though suicide rates are suspected to be very high. Most suicide prevalence studies in Pakistan have focused on medical students due to easier access, reduced stigma around mental health among this group, and their greater willingness to disclose vulnerability and seek help. Multiple studies report over 30% prevalence of suicidal ideation in the past year among medical students.12,13 With proper knowledge and resources, assessing and mapping the prevalence of suicidal ideation and deliberate self-harm among the broader college student population in Pakistan should become a national priority, given their lack of awareness and access to resources.
Establishing surveillance systems to monitor suicidal behaviour on university campuses and collecting accurate data on risk and protective factors would enable the development of targeted interventions that address the specific needs of students in LMICs. This can be achieved efficiently and affordably through online mental health surveys, similar to those conducted by the World Health Organization's International College Student Initiative (WHO-ICSI),14 which utilized the methodologies of the WHO World Mental Health Surveys to assess the mental health care needs of college students across the globe.15
Understanding the etiology of suicidal behaviour among college students is crucial for designing effective suicide prevention programs in LMICs. In HICs, the elevated rates of suicidal behavior among college students are often linked to psychosocial stressors characteristic of this developmental stage, such as increased academic pressure, substance use, bullying, insufficient conflict resolution skills, and the stigma surrounding mental health care access.16,17 These factors undoubtedly contribute to suicidal behaviour among college students in LMICs as well. However, additional contextual factors are likely particularly important in low-resource settings, such as gender-based violence, food and housing insecurity, and financial stress. Understanding the specific context in which students in LMICs experience suicidal behaviour will enable the development of context-sensitive suicide prevention interventions tailored to these settings.
Understanding the cultural context of suicide: There is growing appreciation for the situated meanings that suicidal behaviour holds and the role of culture in the etiology of suicide,18,19 as well as the importance of documenting first-person narratives of suicidal individuals’ lived experience.20 Qualitative research, including ethnographies, of suicidal behaviour in colleges in LMICs will provide insight into the role of cultural factors, like gender roles, norms and religious beliefs. Without this kind of nuanced contextual knowledge, it will not be possible to design culturally appropriate suicide prevention interventions.
Promoting help-seeking and access to mental healthcare: It is well understood that psychopathology is strongly associated with suicidal behavior,21 underscoring the importance of providing accessible, affordable, and evidence-based mental healthcare services on college campuses to prevent suicide. A systematic review and meta-analysis found that individuals with a mental disorder face an almost eight-fold higher risk of suicide compared to those without a mental disorder.22 However, the association between psychopathology and suicidal behaviour appears to be less pronounced in many LMICs. For instance, psychological autopsy studies in China have reported that less than 50% of individuals who died by suicide had a diagnosed mental disorder, 23 while similar studies in India found mental disorders in fewer than 40% of suicide completers. 24 Nonetheless, improving access to mental healthcare remains a critical component of suicide prevention both in the general population25 and among students.7
Despite this, young people experiencing suicidal thoughts often hesitate to seek help, are less likely to access formal treatment, and frequently miss scheduled appointments. 16 In Canada and the USA, a national survey of college counselling centre directors revealed that 80% of students who died by suicide on campus had never used campus-based counselling services. 26 Even when these services are available at no cost, many students do not utilize them due to a lack of knowledge about where to go27 and time constraints. 17
Future research should explore the barriers and facilitators to accessing mental health services on college campuses in LMICs and identify sustainable treatments for common mental disorders that can be delivered in resource-constrained environments. Digital interventions may offer particular promise for closing the mental health treatment gap on college campuses in LMICs, as evidence suggests these can be as effective as standard treatments for mild to moderate common mental disorders.28,29 The need for effective and affordable campus-based mental health services is especially important given the high rates of common mental disorders reported in this population.30
Collaboration and cooperation: Collaboration and cooperation across university campuses in LMICs will be essential to achieve economies of scale and make campus-based interventions affordable in low-resource settings. Additionally, such collaboration can enable economies of scope, potentially making a broader range of interventions available to college students. Establishing a network of researchers and practitioners dedicated to promoting student mental health in LMICs should be a priority for suicide prevention. This network could not only develop sustainable interventions but also test them in controlled and pragmatic trials. A focus on implementation science will be key to the effectiveness of such a collaborative network, facilitating the dissemination of evidence-based suicide prevention interventions and promoting their sustained inclusion in everyday practices and policies on college campuses.31
However, establishing research networks in LMICs presents numerous challenges, like inadequate funding, heavy clinical workloads, limited research support staff, and insufficient research infrastructure and capacity.32,33 Addressing these challenges will be crucial to the success of collaborative efforts in improving student mental health and preventing suicide in these settings.
CONCLUSION
Suicide prevention on college campuses in LMICs is crucial, given the high rates of suicidal behaviour and common mental disorders among this population. However, intervention efforts are hindered by a lack of reliable epidemiological and context-sensitive data. Advancing suicide prevention in these settings requires the establishment of surveillance systems, understanding the cultural context in which student suicides occur, and promoting access to sustainable and effective interventions. Creating research networks would facilitate knowledge sharing and advance research and practice in this important yet neglected field.
Given that suicide is the second leading cause of death among individuals aged 10-34 years, it is imperative for countries like Pakistan, where three-quarters (75%) of the population is under the age of 35 years, to prioritize suicide prevention as a national issue.
REFERENCES
1. Fleischmann A, De Leo D. The World Health Organization’s Report on Suicide. Crisis 2014;35(5):289-91. https://doi.org/10.1027/0227-5910/A000293
2. Värnik A, Wasserman D, Dankowicz M, Eklund G. Age‐specific suicide rates in the Slavic and Baltic regions of the former USSR during perestroika , in comparison with 22 European countries. Acta Psychiatr Scand Suppl 1998;394:20-5. https://doi.org/10.1111/j.1600-0447.1998.tb10761.x
3. Nock MK, Green JG, Hwang I, McLaughlin KA, Sampson NA, Zaslavsky AM, Kessler RC. Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents. JAMA Psychiatry 2013;70(3):300-10. https://doi.org/10.1001/2013.jamapsychiatry.55
4. Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, Vos T, Ferguson J, Mathers CD. Global patterns of mortality in young people: a systematic analysis of population health data. Lancet 2009;374(9693):881-92. https://doi.org/10.1016/S0140-6736(09)60741-8
5. World Health Organisation. Suicide: facts and figures globally. 2022. Accessed on: December 18, 2023. Available from URL: https://iris.who.int/bitstream/handle/10665/360460/WHO-MSD-UCN-MHE-22.03-eng.pdf?sequence=1
6. Mortier P, Demyttenaere K, Auerbach RP, Cuijpers P, Green JG, Kiekens G, et al. First onset of suicidal thoughts and behaviours in college. J Affect Disord 2017;207:291-9.
7. Breet E, Matooane M, Tomlinson M, Bantjes J. Systematic review and narrative synthesis of suicide prevention in high-schools and universities: a research agenda for evidence-based practice. BMC Public Health 2021;21(1):1116. https://doi.org/10.1186/s12889-021-11124-w
8. Mortier P, Auerbach RP, Alonso J, Bantjes J, Benjet C, Cuijpers P, et al. Suicidal thoughts and behaviors among first-year college students: results from the WMH-ICS Project. J Am Acad Child Adolesc Psychiatry 2018;57(4):263-73.e1. https://doi.org/10.1016/j.jaac.2018.01.018
9. Bantjes J, Breet E, Saal W, Lochner C, Roos J, Taljaard L, et al. Epidemiology of non-fatal suicidal behavior among first-year university students in South Africa. Death Stud 2019;46(4):816-23. https://doi.org/10.1080/07481187.2019.1701143
10. Bantjes J, Breet E, Lochner C, Roos J, Kessler RC, Stein DJ. Reducing nonfatal suicidal behaviour among university students: actuarial analysis of potential effects of treating common mental disorders. South African J Psychol 2021;51(1):21-34. https://doi.org/10.1177/0081246320973838
11. World Health Organization. National suicide prevention strategies: Progress, examples and indicators. [Internet]. Switzerland; 2018. Accessed on: December 18, 2023. Available from URL: https://apps.who.int/iris/bitstream/handle/10665/279765/9789241515016-eng.pdf
12. Sami FL, Sheikh NS, Ishtiaq A, Sami HL, Salam E, Ahmed H, et al. Suicidal ideation amongst medical students of Pakistan: A cross-sectional study. J Psychiatry Psychiatr Disord 2020;4(5):343-53.
13. Osama M, Islam MY, Hussain SA, Masroor SM, Burney MU, Masood MA, et al. Suicidal ideation among medical students of Pakistan: a cross-sectional study. J Forensic Legal Med 2014;27:65-8. https://doi.org/10.1016/j.jflm.2014.08.006.
14. Auerbach RP, Mortier P, Bruffaerts R, Alonso J, Benjet C, Cuijpers P, et al. WHO World Mental Health Surveys International College Student Project: Prevalence and distribution of mental disorders. J Abnorm Psychol 2018;127(7):623-38.
15. Auerbach RP, Alonso J, Axinn WG, Cuijpers P, Ebert DD, Green JG, et al. Mental disorders among college students in the World Health Organization World Mental Health Surveys. Psychol Med 2016;46(14):2955-70.
16. Mo PKH, Ko TT, Xin MQ. School-based gatekeeper training programmes in enhancing gatekeepers’ cognitions and behaviours for adolescent suicide prevention: A systematic review. Child Adolesc Psychiatry Ment Health 2018;12(1):12-29. https://doi.org/10.1186/s13034-018-0233-4
17. Czyz EK, Horwitz AG, Eisenberg D, Kramer A, King CA, King CA. Self-reported Barriers to Professional Help Seeking Among College Students at Elevated Risk for Suicide NIH Public Access. J Am Coll Heal 2013;61(7):398-406. https://doi.org/10.1080/07448481.2013.820731
18. Bantjes J, Swartz L. The cultural turn in critical suicidology: What can we claim and what do we know? Death Stud 2017;41(8):512-20. https://doi.org/10.1080/07481187.2017.1333355
19. Abrutyn S, Mueller AS. Toward a Cultural-Structural Theory of Suicide: Examining Excessive Regulation and Its Discontents. Sociol Theory 2018;36(1):48-66. https://doi.org/10.1177/0735275118759150
20. Bantjes J, Swartz L. “What Can We Learn From First-Person Narratives?” The Case of Nonfatal Suicidal Behavior. Qual Health Res 2019;29(10):1497-1507. https://doi.org/10.1177/1049732319832869
21. Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EM, Huang X, et al. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull 2017;143(2):187-232. https://doi.org/10.1037/bul0000084
22. Too LS, Spittal MJ, Bugeja L, Reifels L, Butterworth P, Pirkis J. The association between mental disorders and suicide: A systematic review and meta-analysis of record linkage studies. J Affect Disord 2019;259:302-13. https://doi.org/10.1016/j.jad.2019.08.054
23. Zhang J, Xiao S, Zhou L. Mental
Disorders and Suicide Among Young Rural Chinese: A Case-Control Psychological
Autopsy Study. Am J Psychiatry 2010;167(7):773-81. https://doi.org/10.1176/10.1176/appi.ajp.2010.09101476 25. Manoranjitham SD, Rajkumar AP,
Thangadurai P, Prasad J, Jayakaran R, Jacob KS. Risk factors for suicide in
rural south India. Br J Psychiatry 2010;196(1):26-30.
25. Zalsman G, Hawton K, Wasserman D,
van Heeringen K, Arensman E, Sarchiapone M, et al. Suicide prevention
strategies revisited: 10-year systematic review. Lancet Psychiatry 2016;3(7):646-59.
https://doi.org/10.1016/s2215-0366(16)30030-x 26. Gallagher R. National survey of
counseling center directors. 2005. University of Pittsburgh. Accessed on:
December 18, 2023. Available from URL: http://d-scholarship.pitt.edu/28166/1/2005_survey.pdf 27. Sheffield JK, Fiorenza E, Sofronoff
K. Adolescents’ willingness to seek psychological help: Promoting and
preventing factors. J Youth Adolesc 2004;33(6):495-507. https://doi.org/10.1023/B:JOYO.0000048064.31128.c6 28. Lattie EG, Adkins EC, Winquist N,
Stiles-Shields C, Wafford QE, Graham AK. Digital Mental Health Interventions
for Depression, Anxiety, and Enhancement of Psychological Well-Being Among
College Students: Systematic Review. J Med Internet Res 2019;21(7):e12869. https://doi.org/10.2196/12869 29. Bantjes J, Kazdin AE, Cuijpers P,
Breet E, Dunn-Coetzee M, Davids C, et al. A Web-Based Group Cognitive
Behavioral Therapy Intervention for Symptoms of Anxiety and Depression Among
University Students: Open-Label, Pragmatic Trial. JMIR Ment Health
2021;8(5):e27400. https://doi.org/10.2196/27400 30. Auerbach RP, Mortier P, Bruffaerts
R, Alonso J, Benjet C, Cuijpers P, et al. Mental disorder comorbidity and
suicidal thoughts and behaviors in the World Health Organization World Mental
Health Surveys International College Student initiative. Int J Methods
Psychiatr Res 2018;28(2):e1752.https://doi.org/10.1002/mpr.1752 31. Bauer MS, Damschroder L, Hagedorn
H, Smith J, Kilbourne AM. An introduction to implementation science for the
non-specialist. BMC Psychol 2015;3(1):32. https://doi.org/10.1186/s40359-015-0089-9. 32. von Saint André-von Arnim AO,
Attebery J, Kortz TB, Kissoon N, Molyneux EM, Musa NL, et al. Challenges and
Priorities for Pediatric Critical Care Clinician-Researchers in Low- and
Middle-Income Countries. Front Pediatr 2017;22;5. https://doi.org/10.3389/fped.2017.00277 33. Fischer SE, Alatise OI, Komolafe
AO, Katung AI, Egberongbe AA, Olatoke SA, et al. Establishing a Cancer Research
Consortium in Low- and Middle-Income Countries: Challenges Faced and Lessons
Learned. Ann Surg Oncol 2017;14;24(3):627-31. https://doi.org/10.1245/s10434-016-5624-2
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