Prevalence of Suicidal Ideation and Suicidal Cognition among the Local Population of Karachi, Pakistan

Objective Suicide has become a leading cause of death worldwide, thus it has become a public health problem for every country in the world and thereby in Pakistan too. The aim of present study was to find out the prevalence of suicidal thoughts among the local population of Karachi. Correlations were also assessed among suicidal thoughts and demographic characteristics. Method A survey was conducted to fill out a pre-structured questionnaire from the participants between the age group of 18-30. The questionnaire contains Beck’s scale of suicide cognition, Modified scale of suicide ideation and a detailed demographic profile. Subjects were taken from different universities, medical colleges, offices and business schools. Mentally ill patients were not included in the study. Result Severe Suicide ideation and suicidal cognitions are prevalent in the population to about 4% and 3% respectively. Also in the study, demographic variations exist in subjects with respect to suicidal thoughts; male, non-working, unhappy, in-pain subjects, unmarried, being in the 18-21 age brackets and undergraduate reported higher suicidal thoughts as compared to their correspondent parameters. Conclusion It has been concluded that severe suicidal thoughts are prevalent among youngsters. And certain demographic characters are strongly correlated with amplified suicidal thoughts among youth of Karachi.


Introduction
According to the recent report of World Health Organization of 2006, about a million people, commit suicide every year in the whole wide world, which is far more than the deaths occurred in wars (WHO, 2006;Kessler et al, 2005& Mann, 2003. Thus suicide has become a public health problem affecting entire world at every level with devastating socio-economic cost and consequences (WHO, 2013& Mann, 2003. It is also revealed that after every 40 seconds a person takes his or her life somewhere in the world (WHO, 2006). In general, rates are highest in Eastern Europe and lowest in Central and South America, with the United States, Western Europe, and Asia falling in the middle (Bertolote & Fleischman., 2009& Nock, et al., 2008. Previously researchers define suicide as "an outcome of deliberate obliteration or killing of oneself" (Kaplan, et al., 1998). Similarly, Krug in 2002 defined suicide as "an outcome of deliberate acts of the person with considerable initiation and performance of a pattern to knowingly kill oneself" (Krug, 2002). Meanwhile, the word suicide is etymologically derived from a Latin word, suicidium (Sui=oneself and Cidium=killing) (Jans, et al., 2012).
However, the notion, thought and imagination of self-harm comes under the umbrella of suicide ideation (Jacobs, et al., 2003& Kaplan, et al., 1998, which is way more common than the actual suicide attempts. Further, it was specified that the ratio of suicide ideation to suicide attempts is about 8 to 10 times higher, which means that people ideate suicide 8 to 10 time more than they actually attempt it (Frierson, et al., 2003& Andreason, et al., 1995. On the other hand, attempted suicides are 10 to 40 times more frequent than lethal suicides (Schmidtke, et al., 2004& Platt, et al., 1992. Therefore, each suicide (whether attempted or completed) is an individual's own catastrophe who takes his or her life captivating under the dilemmas of life. And this tragic act will unceasingly and vividly influence the lives of his or her family and companions till the very end (WHO, 2013). Similarly, Redfield Jamison described the sentiments of suicidal mind as,

"Suicide carries in its aftermath a level of confusion and devastation that is, for the most part, beyond description" (Redfield Jamison, 2000).
The estimated ratio of attempted suicides to completed suicides among adolescents to be 50:1 to 100:1 respectively; at which each adult already had 20 other suicide attempts before he or she could actually die by suicide (WHO, 2013 , 2003) and are predicted to be increased as much as 2.4% in 2020 (WHO, 2013).
Though there is a plenty of data regarding attempted suicide and completed suicide throughout the world, but little has been researched in relative to the suicidal thoughts, including suicide ideation and suicide cognition; which has proven to be the basic markers of suicidal activities. The present study is thereby conducted to shed some lights on the ground scenarios and milieu on suicidal thoughts, which are the root causes of these increased suicidal acts. The prevalence of suicidal ideation and suicidal cognition has been pondered among the local population of Karachi, Pakistan. Also in this study, different demographic components, like age-group, gender, marital status, life style etc. has been correlated with suicidal ideation and cognition.

Methodology
Subjects Participants were recruited from different universities and medical colleges of Karachi. Subjects of this study were mostly undergraduates, however, pre-graduates and post graduates were also included. Moreover, the age criterion was set to be 18-30 years who did not have any disorder or any kind of mental illness, whether acute or chronic.
Tools A pre-structured questionnaire was interviewed from the participants who showed their interest in the present study and voluntarily agreed to give their concerned information regarding this study. The questionnaire included three parts in which the first portion has a detailed demographic information, the second one comprised of a universally recognized scale for suicide cognition, the suicide cognition scale (M.D. Rudd, et al., 2007) the remaining third part included The Modified Scale for Suicidal Ideation (MSSI) (Miller, et al., 1986) respectively. Consent is also attached for ethical purpose in which individual is asked to read out some details about the study and if he or she agrees to take out 10-15 minutes to fill it out; then an agreeable signature is taken and the interview is started. Meanwhile, a free space was also given in the questionnaire so as to provide participants with liberty to express their trauma and suicidal thoughts. The personal information however remains confidential and not shared at any level with individual's specificities.

Data analysis
The collected data was compiled from 519 subjects, of which 247 were female participants and 272 were males.
The data was sorted into different groups, according to the severity of parameters been analyzed. The variables are then correlated to each other to evaluate the possible relationships among them. Moreover, frequencies of some variables are also assessed. The data is initially analyzed through standardized scoring schemes of scales along with the demographic profile using MS Excel 2010. Later the data was shifted to SPSS version 2.0, for graphical analysis and correlations of different variables altogether.

Results
The results of this study are showing in the graphical manner under this heading.

Discussion
The prime objective of the study was to measure the prevalence of suicide ideation and suicide cognition among the local population of Karachi. Though, results summarized that about 42% of the population is having low suicidal ideation and an approximately same ratio of the populace have mild suicide ideation, which is prone towards severity as shown in Figure 1.0. The shocking revelation was that 4 in every 100 persons are severely ideating suicide in this population which is an alarming call for the whole country. Similarly, 3 individuals in every 100 subjects are having severe suicide cognition ratio as shown in Figure 1.1. Previous studies quoted that suicidal ratio among Muslim countries and other Asian countries are lowest as compared to non-Muslim countries (Bertolote & Fleischman, 2009& Nock, et al., 2008. But these rising suicidal ideation and suicidal cognition among Karachi, Pakistan are leading us among those highly suicidal countries. The current study also shows the intensity and frequency of suicidal thoughts with respect to different demographic characteristics of the population. The reported results of the survey and analytical measures reflect that some gender variations are present with respect to suicide ideation. Males ideate suicide more than females which is in the line of previous studies, who concluded that males are more supportive of the idea of suicide as compared to female (Domino & Leenaars., 1989;Domino, MacGregor, Hannah, 1988-89;Limbacher & Domino, 1985-86.) as it can be seen in Figure  1.2 and Figure 1.3. Similarly, another account of studies suggested similar resulted in a way that men are more likely than women to kill themselves (American Foundation for Suicide Prevention, 2007. Sejong, et al., 2005Canetto & Lester, 1995). With respect to social status, it is estimated that a major ratio of the sample was found to be normally social thereby suicidal ratings are condensed at this level, as it can be seen in Figure 1.4. However, it is observed that severe suicidal ideation is found more in people who are socially active. In the meantime, mild suicide cognition exists in every social status, shown in Figure 1.5. This may be due to the fact that youth is more socialized now, no matter what they feel and think; they tend to express it to as many people as they can. Nonetheless, the results are contrary to previous studies that suggested that strong social relations likely to decrease suicidal risks (Meadows, 2005).
Relationship commitments have always been a protective factor for any kind of risky behavior including suicide. The study concluded similar results by showing high suicide ideation and suicide cognition among single and divorced ones while lowest rates among engaged and married ones; which shows that the committed ones are not likely supportive with the idea of suicide as compared to the loners or singles shown in Figure 1.6 and Figure 1.7. Justifiable researches include (Lorant, et al., 2005), who stated that marriage has a buffering effect on suicidal risk in the population. Similarly, (Agerbo, 2005;Gove, 1979;Qin, Agerbo, & Mortensen, 2003& Jans, et al., 2012 are further studies summarized in the same array.
The age group in which suicidal ideation and cognition is more prevalent is found to be 18-21, agreeable by a range of past researches including (WHO, 2013;National center of health statistics, 2009;McKeown, et al.,2006;Kaplan, et al., 1998;Jacobs, et al., 2003;Watkins, 2006;Quin, 2005, Department of health statistics, 2000National Youth Violence Prevention Resource Centre, 2006;Masango, et al., 2008& Waldvogel, et al., 2008. Department of health statistics notes, 2000, see Figure 1.8 and Figure 1.9. The age group which is generally considered to be young adult age has higher suicidal prevalence which may be due to the fact that the maturity has not yet hit these individuals. Researches claimed that human brain has not developed completely till this age bracket as prefrontal cortex is still in developing stage. This immaturity reflects in their behavior and they end up ideating and even attempting suicide for few minor invalid reasons. Further, in this study, suicide cognition is shown to be associated with employment. Generally, where there is un-employment; there comes depression, anxiety, hopelessness and thereby suicide ideation. The results are similar here; unemployed subjects reflect high suicide ideation and suicide cognition, when compared to employed ones, see Figure 2.0 and Figure  2.1. In 2000, Platt and Hawton found similar results and they concluded that suicidal risks are increased among un-employed people (Platt & Hawton, 2000). Similarly, Kraut and Walld in 2003 showed association of unemployment with higher likelihood of suicidal behaviors. Though, they compared unemployment with part time job and full time job in their study (Kraut A. & Walld R, 2003).
When life-style was compared with respect to the suicidal thoughts, it was seen that people with active life-style tend to have intensified suicidal ideation and suicidal cognition as compared to those who have sedentary lifestyle, consider of the possible reasons behind these results would be the hyper secretion of epinephrine and nor-epinephrine in these individuals. This hyper-secretion would let them stay active, and sometime very active, but suicidal are occupied their place in their minds.
In addition to it, the level of qualification influences suicidal behavior as well. Subjects, who are pursuing graduation show high rates of suicidal ideation, consider Figure 2.4. The results are in the line of Minear and Brush (1980-81). This may be due to the peer pressures they are experiencing in their graduation life. Further participants who did matriculation and intermediate and also post-graduated ones reflect comparatively lower suicidal ideation and cognition, consider Figure 2.5.

Conclusion
The present study concluded that suicidal thoughts, including suicidal ideation and suicide cognition are widespread among the younger population of Karachi. And these prevalent self-harming thoughts are simultaneously linked with the demographic characteristics. Mild to moderate suicidal thoughts exist dominantly in males but the severity cases are almost equally prevalent among both genders. Similarly, being single and, aged 18-21, increases the risk of suicidal thoughts among youth. It is also analyzed that undergraduate students perceive suicidal thoughts more than any other educational level. Similarly, non-working subjects think about suicide more as compared to working individuals.

Recommendations
The future recommendations in regards to suicidal behavior, in general mental health, are more pronounced towards research area and awareness sessions on mental wellbeing. Thus, in every country, there should be launched some educational and awareness campaigns for the locals in order to spread the words on mental health. For this to happen, the main goal is to treat barriers in treatment and care by increasing awareness of the frequency of mental disorders, their treatability, their recovery process and the human rights of people with mental health. Ultimately, well planned public awareness and educational campaigns can reduce stigma and discrimination, increase the use of mental health service, and bring mental health and physical health come closer to each other.
Furthermore, new researches into biological and psycho-social aspects of mental health are needed in order to increase the understanding of mental disorders and to develop more effective interventions.
Conclusively, the study suggest that, through educational forum we can spread the awareness of significance of mental health in correspondence with the physical well-being; because one has to maintain a balance between the two in order to enjoy a complete circle of life.