Patterns of Suicide in Kuwait: a retrospective descriptive study from 2003–2009

This study was designed to investigate the patterns of suicide in the State of Kuwait. It is the first of its type to study the different demographic parameters (age, gender, religion, nationality and Governorate) in the reported suicides in this country. It was of paramount importance to perform the necessary analyses to determine the basis of the suicide problem in Kuwait. This will subsequently help the Kuwaiti Government tackle the problem and reduce the number of suicides in the country.

The results presented in this study highlight a number of interesting details, which will be discussed in the following account. We will also briefly discuss the rates of suicide in other Middle Eastern Countries, mainly for comparison with our study, as many of these countries share similar social and cultural parameters with Kuwait.

Suicide is one of the leading causes of death in the world, and suicidal attempts constitute a major public health concern [3]. The total number of 347 cases in our study was small compared to the absolute numbers reported from many other countries around the globe. For a country such as Kuwait with a population of approximately 1.5 million in 2003 and 2 million in 2009, this number is quite high.

Hanging was the leading method of suicide, while jumping from a height was the least common method. A possible explanation is that jumping from a height constitutes a horrible experience for the person committing suicide. Moreover, it may be viewed and noticed by others. On the other hand, suicide by hanging has some privacy associated with it, although the mechanism of death is complex [4].

Males outnumbered females in all methods of suicide except in jumping from a height, for which the percentage of females was greater. Saudi Arabia shares a border with Kuwait, and the two countries share an almost identical culture. In Saudi Arabia, 82 % of suicides were among males [5]. All victims of firearm injuries in Saudi Arabia were males. The most plausible explanation for this observation is that gun ownership is limited to men by regulations of the country.

The most common method of suicide in our study and in similar studies in the Middle East is hanging [6]. In contrast, in a Scottish study, poisoning was the most preferred method of suicide [7]. Rates of suicide in most countries in the world, including Denmark, are higher among males, which is consistent with our results [8, 9]. China is an important exception, with a very high suicide rate among females, especially young women in rural areas [10]. However, there has been a recent trend of reduced female and increased male suicide in China [11, 12].

The results of this study have clearly shown that all categories of suicide occurred more frequently among the non-Kuwaiti population, except for firearm injuries. Jumping from a height was reported exclusively among non-Kuwaiti suicide cases. Most of these victims were housemaids who could not run away from the ill treatment of their employers. Similar results were reported in Bahrain, another neighbouring gulf country with similar customs and traditions to Kuwait. The mean suicide rate was 0.6 per 100,000 for Bahraini nationals and 12.6 per 100,000 for expatriates. Indian immigrants in Bahrain demonstrated the highest suicide rate [6]. Similarly, in Saudi Arabia, more expatriates (65.4 %) committed suicide than Saudi citizens (36.4 %) [13].

No significant difference in suicide rates was observed between married and single subjects. However, other studies comparing socio-demographic characteristics revealed that a higher prevalence of suicide was associated with female gender, lower education, poor financial perception and single marital status [14, 15].

There is limited data in the literature on the relationship between marital status and suicidal behaviour in the Middle East [6]. A recent study from Japan concluded that single people committed suicide more often than married people [16]. New reports in 2010 published by the Office for National Statistics in the United Kingdom (UK) indicated that suicide rates among single and divorced subjects were approximately three times higher than corresponding rates in married subjects of both genders between 2000 and 2009 [17]. Their results showed that 30.8 single men per 100,000 died by committing suicide in the UK, compared to 10.6 per 100,000 married men. In the same period, 10.3 single women per 100,000 succumbed to suicide compared to 3.6 per 100,000 married women. The authors suggested that single people of either gender are more vulnerable to depression than married people.

Farwania Governorate ranked first in suicide prevalence followed by Ahmady, Jahra, the Capital, Hawally and Mubarak Al-Kabeer. The Farwania and Ahmady Governorates are heavily populated with expatriate labourers who work at factories and cleaning companies. These Governorates have many buildings where apartments are sublet by tenants in order to earn more money or cover their own expenses. These areas are therefore overcrowded and difficult to monitor by authorities. As a result, suicides are higher in these Governorates. Data provided by the MOI in March 2010 revealed that the Farwania and Ahmady Governorates have high crime rates [18]. Many individuals who live in these Governorates possibly retaliate by committing crimes or become part of a criminal gang to gain extra income. It is now well known that these depressed areas in Kuwait are a true fortress for many organized crimes, and as a result, many people are stressed and under severe pressure due to gang crimes. Depression and stress are forerunners of suicide.

Significantly more people in our study committed suicide in their prime and productive years of life compared to other periods. Approximately 71 % were between the ages of 20 and 39. The extreme age categories were the least vulnerable to suicide, with a prevalence of 5.7 % in the under 19 group and 2.9 % in those over 60. Similar results were found in India, where studies have highlighted that the most common age group of suicide victims was 21–30 [14, 15]. In contrast, in the United States of America (USA), a study in 2009 showed that suicide was the third leading cause of death for young people between the ages of 15 to 24 [19, 20].

Traditionally, poison (poisoning) has been one of the most commonly used substances for suicide and homicide. In our study, suicide due to poisoning was the third most common suicide modality. A study conducted in Egypt revealed that female adolescents are at a higher risk of self-poisoning [21]. Deliberate self‐harm is a major problem in the developing world; widespread availability and easy access to poisons make it easier for the vulnerable to commit suicide [22]. This situation is quite often found in cases of drug overdose, which is another method of committing suicide [23]. A study was conducted in an addiction treatment centre in a psychiatric hospital in Kuwait to review cases of poisoning in order to identify the main poisons used for self‐harm in this region [24]. The results showed that pesticides were the most prevalent type used, followed by paracetamol (acetaminophen). Both of these products are readily available in any grocery store.

In 2009, the government of Kuwait reported that most cases of attempted suicide were by ingestion of pesticides or paracetamol (acetaminophen) [25]. These drugs have become the most popular method of self‐harm due to their ready availability in residential areas, especially among people from the Bangladeshi community who live in Kuwait. In India, medicines such as benzodiazepines and antidepressants were those most commonly used by victims of self-poisoning [14, 15]. The previous data provide strong evidence to support the restriction of some drugs that are easily available over the counter in shops and in supermarkets to combat the blatant abuse that can lead to suicide [26, 27].

Suicide by firearm injuries was uncommon in our study. Guns are one of the most effective means for committing suicide and are a far more prevalent suicide method than drug overdose, strangulation or cutting oneself in the USA [28]. Given the high rate of gun ownership in the USA, it is logical to expect a direct link between increased access to guns and a high incidence of suicide. However, international data show that higher levels of gun ownership do not always correlate with higher levels of suicide [29]. For example, personal gun ownership is more prevalent in Switzerland than in the USA, but suicide rates are higher in the USA [30]. The actual chain of events leading to selection of a firearm as a means of death is unclear. In fact, there are some mediating factors that contribute to firearm suicide. People consider suicide by firearm as an honourable and quick way to eliminate personal troubles and disappointments. Easy access to dangerous weapons is also an important risk factor. Many Kuwaitis have guns in their possession as a result of the gulf war in 1990, and many campaigns are spearheaded by the MOI to collect weapons that are in the possession of residents and citizens without a valid permit.

Table 4 compares suicide rates in the Arabian Gulf and selected Arab and Middle eastern countries in the year 2002 [31]. Kuwait had one of the highest rates in the region. The suicide rate in Kuwait has increased from 3.2/100,000 in 2002 to 6.1/100,000 in 2010 [31], while the rate fluctuated between these two values throughout the period of the study. The literature has limited reports on suicide in the Middle East. However, the 2002 rates according to the WHO website (http://​apps.​who.​int/​en/​) are similar to the rates observed during the study period (2003–2009). Reports of the suicide rate in Bahrain in 1988 show similar values to that in Kuwait (5.4/100,000) [31] and have increased in 2012 to reach 8.1, according to the WHO website. Most Arabic families of suicide victims would never admit the actual cause of death to anyone and always state that their son or daughter died suddenly. Moreover, due to the negative views that the general population has against autopsies, many suicides probably do not reach the forensic office, as families will try and bury their loved ones quickly and are compassionately given death certificates from authorities without the word ‘suicide’ written anywhere. Saudi Arabia views suicide as a disgraceful and shameful act more than any other Arab or Muslim country [32]. Similar results have been found in the United Arab Emirates, in which the annual rate of suicide in Dubai between 1992 and 2000 was approximately 6.2/100,000 [33, 34]. We found no significant difference in suicide incidence between Muslims and non-Muslims, despite the fact that suicide is prohibited in Islam and is regarded as a sinful act similar to homicide. It appears that the stresses and probable depression that suicide victims feel prior to their demise supersede any religious teachings.