Suicidal behaviour across the African continent: a review of the literature

Each year, the World Health Organization (WHO) estimates that almost a million people die from suicide worldwide [1] highlighting suicide as a serious global public health concern. The contribution of suicide to the global burden of disease is predicted to increase over future decades [2]. Data from the WHO mortality database indicate that 85% of the world’s suicides occur in low and middle income countries (LAMIC) [3], however, most of our knowledge and understanding about suicidal behaviour is based on information from high income countries, which may not be applicable in different cultural contexts.

Africa is the world’s largest and second most populous continent, with a population of over one billion people. The continent is heterogeneous, comprising rural, semi-rural and urban areas, a diverse range of religions, ethnic groups and cultures and several regions affected by war, political and economic instability. Despite high overall mortality rates [1] suicide rates in Africa have been thought to be very low [4]. However, little is actually known about the incidence and patterns of suicide across the continent. This information is of fundamental importance, both to help inform local, regional and national policy, and to provide a more accurate estimate of the magnitude of suicide globally.

Suicide research in Africa is limited by a lack of systematic data collection. With less than 10% of African countries reporting mortality data to WHO, official statistics are available for only 15% of the continent’s total population. Much of the available published suicide data are based primarily on small studies conducted in different regions and populations. Moreover, reported suicide mortality statistics are likely to underestimate the true magnitude of the problem as religious and cultural sanctions may lead to suicide being under-reported, misclassified or deliberately concealed.

Even less is known about attempted suicide across the African continent. It is estimated that for every suicide that occurs worldwide there are up to 20 suicide attempts [5]; however reliable data are not available for most countries. Data are often obtained from hospital records which underestimate the number of cases, as many individuals are only admitted to hospital if in a critical condition. Moreover, a lack of access to medical facilities, particularly in rural areas of Africa, means that many suicide attempters are unlikely to present to hospitals. As with suicide, socio-cultural factors also contribute to under-reporting.

This paper reviews the published literature on suicide and suicide attempts in Africa to address these knowledge gaps. Specifically, we aim to:

A systematic search of PubMed, Web of Knowledge, PsycINFO, African Index Medicus, Eastern Mediterranean Index Medicus and African Journals OnLine was conducted for papers published between January 1998 and June 2013 that investigated fatal and non-fatal suicidal behaviour in an African country (incidence, methods or risk factors). Reference lists of relevant papers were examined for additional eligible studies and two of the authors (SB, HH), who have a longstanding interest in researching suicide in Africa, identified additional published publications from their personal collections of papers (Figure 1).

There has been much debate regarding the most suitable terminology to describe suicidal behaviour, a discussion of which is beyond the scope of this paper. In line with a newly proposed nomenclature for suicidal behaviour [6, 7] we will use the term ‘suicide’ to refer to suicidal acts that result in death and ‘suicide attempts’ to refer to suicidal actions that do not result in death. Evidence of suicidal intent (whether explicit or implicit) is central to this definition, however, intention is often difficult to establish. It is possible that in some instances, acts of deliberate self-harm involving no suicidal intent may have been included.

The search was conducted using a combination of the following search terms: Suicide [Mesh] or suicid? [tw] or ideation [tw] or self harm? [tw] or self injur? [tw] and was restricted to articles published in English, German or French. The precise approach varied across the different databases. Papers were manually reviewed to assess eligibility for inclusion. In line with a public health perspective on the overall burden of suicide and suicide attempts across the continent, we focused on general population samples of adults. Case reports and publications focused on one sex or age group only (e.g. children and adolescents), or groups considered at high risk for suicide (e.g. patients attending psychiatric institutions, patients suffering from HIV/AIDS) were not included.

For those countries with more than one eligible publication (e.g. South Africa), the best available data are presented; these were selected according to several criteria including the recency of the publication, total population coverage and level of detail available. National-level suicide mortality data for the five countries that report data to WHO (Mauritius, the Seychelles, South Africa, Zimbabwe and Egypt) was obtained from the WHO mortality database [8].

Knowledge about suicide in Africa is limited with less than 10% of countries reporting mortality data to WHO. This investigation aimed to increase our understanding of the prevalence, patterns and risk factors for suicide and attempted suicide across the continent by reviewing and consolidating the available literature.

Suicide incidence rates have been reported in only 16 countries which together account for approximately 60% of the total population of Africa. However, national-level suicide data are lacking for most of these countries. There was considerable variation in the rates reported, both within and across countries. This could reflect the unreliability of the data, or alternatively could highlight the importance of the cultural context. Suicide rates in urban South Africa are reported to be much higher than in the other countries [22], perhaps due to the better quality and reliability of mortality data available.

Based on the limited available data, we crudely estimated the annual number of suicides in Africa to be approximately 34,000 [inter-quartile range 13,141 to 63,757]. This figure was calculated from median incidence rates [according to mortality strata] and is intended to provide only an approximation to the incidence of suicide in Africa. This estimate is somewhat lower than the recent GBD 2010 estimate of 49,558 deaths [34], however our figure is based only on available published data and does not take into account the geographical, sex or age structure of countries. It is not possible to judge which estimate is more accurate as each is based on different sources and assumptions. Any current estimates of suicide in Africa need to be interpreted with great caution given the absence of data for many countries, the variability of estimates and the lack of national-level statistics. Moreover, the huge cultural and religious diversity found both within and across African countries together with geographic (i.e. rural/urban), economic and political differences mean results based on data from one population or region are unlikely to be generalisable to another. Additional research is urgently needed, particularly in rural and economically deprived regions where suicide data are largely absent. Studies from India, China and Sri Lanka indicate that rural areas have exceptionally high rates of suicide [62‐64], most likely due to easy access to pesticides combined with poor access to medical facilities and ineffective treatments.

The lifetime prevalence of suicide attempts also varied across studies, with a median estimate of 2%-3% [range 0.7-6.0%]. This compares with 0.4-4.2% found in the WHO SUPRE-MISS community survey of LAMICs [40] and 2.7% from the 17 countries in the World Mental Health Surveys [65]. Worldwide it is estimated that there are up to 20 suicide attempts for every suicide death [5] but across much of the African continent, the ratio of deaths to attempts appears to be much lower than this. Whilst this ratio does vary globally by country and suicide method, it could indicate that the true incidence of suicide in Africa is underestimated. In many African countries, suicidal behaviour carries negative religious and cultural sanctions and therefore may be under-reported, hidden or deliberately misclassified. In addition, the uncertainty in establishing suicidal intent may lead some suicidal acts to be misclassified as unintentional. There is some evidence from South Africa to suggest that suicide deaths by poisoning, jumping and railways are more likely to be misclassified than those by firearms or hanging [66].

Worldwide, three to four more men die by suicide than women. The ratio is much lower in Asian countries [67, 68] and in China, more women die from suicide than men, particularly in rural areas [62, 63, 68]. Available evidence from Africa suggests that sex differences in suicide are broadly consistent with international trends, with all countries reporting a male predominance, typically at a ratio of 3.0:1 or higher. However, most studies have been conducted in urban areas and it is not clear whether this pattern would also be seen in rural areas of Africa. The sex discrepancy identified in this review may in part be explained by a propensity for men to use more lethal methods such as hanging and firearms, whereas the most common method used by women was poisoning.

Clear conclusions cannot be made regarding sex differences in attempted suicide in Africa as some studies reported a male predominance, some a female predominance, and others no clear sex differences. These findings contrast with international trends where suicide attempts tend to be 2–3 times higher in women than in men [50, 69].

Knowledge of the most prominent methods used for suicide in Africa is vital for the development of prevention strategies, as restricting access can be an effective way of reducing suicide rates [2, 70, 71]. According to WHO, pesticide poisoning is now the most common method of suicide worldwide [72] and is frequently reported in China, Sri Lanka and India, particularly in rural areas [64]. Findings from this review suggest that pesticide poisoning is also a prominent method in Africa. Moreover, the proportion of suicidal acts involving pesticides is likely to be underestimated as data are largely absent in rural areas where pesticides are easily accessible and likely to be a commonly used suicide method. Evidence from Sri Lanka [73, 74] suggests that reducing access to pesticides by banning those that are most toxic to humans is an effective means of reducing suicide rates. Improved medical management for pesticide poisoning is also urgently needed in order to reduce the lethality of this method. Poisoning with over-the-counter medications was also a common method used in both suicide and suicide attempts. Legislation regarding quantities of over-the counter medication may help to reduce overdose rates [75].

Given their high lethality, it is not surprising that rates of hanging and firearms were higher for suicide than for suicide attempts. The use of firearms as a method for suicide varied considerably across studies [range 0-32%], probably reflecting differences in the availability of this method. Prevention approaches should focus on restricting access to firearms and promoting safer storage [70, 71].

A greater understanding of the antecedents to suicide is important in order to identify high-risk groups and to develop effective prevention strategies. Suicide is multi-factorial, involving a complex interplay of biological, social, cultural and psychological factors. Information about suicide risk factors in Africa is typically obtained retrospectively, either from medical records which are often incomplete, or from relatives’ reports which may be biased. Case control and cohort studies are required to better characterise risk factors for suicidal behaviour in Africa. For example, several studies reported high rates of unemployment amongst those who had died by suicide; however, as rates of unemployment are generally high within the population, the absence of a suitable comparison group means that these data are not informative.

Risk factors for suicide and suicide attempts identified in this review include physical health problems, psychiatric disorder or symptoms, drug and alcohol use/abuse, interpersonal and social difficulties and socioeconomic problems. The type of risk factors that are identified and their relative importance is likely to vary across different regions and population groups. The importance of taking into consideration the socio-cultural context has been highlighted by qualitative studies [59‐61]. Such studies are crucial in order to build locally relevant suicide theory and to understand how, when, where and for whom risk factors may be connected to suicidal behaviour [57, 58].

Knowledge about suicide and suicide attempts in Africa is important, not only for African policy but also to improve the precision of global estimates of the magnitude of suicide. Findings from this review suggest that suicide is an important public health issue in Africa, with reported figures highly likely to underestimate the true incidence. Systematic data collection is urgently required in order to compile reliable suicide mortality and morbidity statistics across the continent. There is also a need for more qualitative studies, which are able to take into account the socio-cultural context.