The present study documents the high burden of suicidal behavior in the general population of Afghanistan, and the association with established risk factors for suicide including psychiatric disorders and experiences of trauma. We document strong and significant associations with traumatic event exposures, especially those involving sexual violence, with suicidal behavior, as well as associations with psychiatric disorders across a broad range of symptoms, including depressive, anxiety, psychotic and substance use disorders. To date, this the largest psychiatric epidemiological study of the Afghan general population conducted, and we document the need for increased mental health support infrastructure throughout the country. Given that political events have escalated in the country, especially in 2021, a continued focus on Afghan mental health is critical to public health in the regions. Suicide, including both death by suicide and injuries that result from intentional self-harm, continue to be major drivers of morbidity and mortality worldwide, and outcomes that are preventable with accessible mental health and social support. Ensuring that such supports are in place across the world, including vulnerable regions such as Afghanistan, is critical to building global mental health.
The findings from the general population of Afghanistan are higher than with those from other low to middle income regions; Borges et al. documents 12-month ideation rates of 2.4% (SE = 0.1) for females and 1.6% (SE = 0.1) (Borges et al. 2010). Rates for low and middle income countries are generally are slightly lower than for high income countries, which have prevalence rates of 2.2% for females and 1.7 for males for 12-month suicidal ideation. An European multi-country study showed large differences across European countries, especially among women, with rates consistent with the rate of suicidal ideation among Afghan women (e.g. 14.9 in France, 13.1 in Portugal) as well as attempts (e.g. 4.9% Portugal, 5.4% in France).
Reporting on data from 21 countries that were part of the WHO World Mental Health surveys, Nock et al. (2009) documented increases in the risk of suicidal behavior among those with psychiatric disorders of approximately 1.5 to 3 fold (Nock et al. 2009). In Afghanistan, we found many associations in a similar direction and magnitude, and even higher for proximal suicidal behavior such as past 12-month ideation. Nock et al. (2009) also found that overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive (Nock et al. 2009). Results revealed that approximately 80% of suicide attempters in the United States have a temporally prior mental disorder. Anxiety, mood, impulse-control and substance use disorders all significantly predict subsequent suicide attempts; however, these associations decrease substantially in multivariate analyses controlling for comorbidity but remain statistically significant in most cases (Nock et al. 2010). Further, these results are in line with other psychiatric epidemiological studies that have documented the serious public health risk of exposure to trauma for suicidal behavior. A meta-analysis in 2018 concluded that depressive disorders increase risk for suicide ideation, attempt and death and is one of the strongest predicators of suicide (Ribeiro et al. 2018). Another study found that anxiety is a statistically significant, yet weak, predictor of suicide ideation and attempts, and that PTSD is among the strongest associations for suicidal behaviors (Bentley et al. 2016). indeed, interventions to address future suicide risk among those exposed to trauma are a key are for implementation science and methodological innovation in program and treatment development. Substance use disorders are a consistent risk factor for suicidal behavior, consistent with our results (Artenie et al. 2015a; Artenie et al. 2015b). Our results underscore the importance of such efforts, especially in areas with high levels of trauma exposure. Studies in Afghanistan, including our own, indicate that there are mental health treatment gaps, much like there are in many areas of the world, highlighting the need not only for intervention implementation but also capacity building for a mental health workforce.
Our results on demographic predictors of suicide are also consistent with other research, documenting that social identity and socio-economic status remain robust predictors of suicide risk throughout the world. Risk factors for suicidal behaviors in both developed and developing countries that are confirmed in these data include female sex and lower education and income (Borges et al. 2010; Qin et al. 2003). There is abundant evidence indicating that low socioeconomic position, irrespective of the economic status of the country in question, is associated with an increased risk of suicide, including the suggestion that the recent global economic recession has been responsible for an increase in suicide deaths and, by proxy, attempts. These data also indicate regional variation in suicidal behavior within Afghanistan, with the central and southern regions at particularly increased risk. Reasons for regional variation remain speculative. The central region of Afghanistan includes major urban areas such as Kabul; residents may be more willing to disclose suicidal behavior in these areas and more likely to have connected with mental health services. The southern regions have significant areas of ongoing political conflict, a high rate of immigrants, as well as burdensome living and marital conditions that place individuals at increased risk. Given that spatial clustering of suicides and suicidal behavior remains an important area of research,(Keyes et al. 2021) greater emphasis on understanding spatial aspects of suicide risk in high-conflict settings such as Afghanistan is important for future research.
The mechanisms that underlie the associations between trauma exposure, psychiatric disorder, and suicide risk are well documented. Individuals enduring trauma, especially when there is grave threat to physical integrity and bodily harm, are at increased risk for feelings of hopeless, intrusive reexperiences of trauma, and feelings of disassociation and inability to feel closeness to loved ones (Ásgeirsdóttir et al. 2018; Bath 2008; Beautrais 2002; Nolen-Hoeksema 2012). Social isolation and fear of reporting or continued harm can also render difficult emotional pain leading to suicidal crises (Möller-Leimkühler 2002; Nock et al. 2010). Further, witnessing trauma can also lead to intrusive and unpleasant thoughts and emotions, bereavement for those lost in the circumstance of violent trauma to others, a fear of retaliation or ongoing physical threat (Panagioti et al. 2015). The magnitude of the emotional response to trauma is evident in the results that we present here, with almost all traumas increasing the risk of suicidal behavior across the lifecourse.
Suicidal behaviors were more prevalent on women than men in univariate as well as in multivariable analyses: wishing to death, lifetime suicidal thoughts and moreover suicidal attempts occurred at approximately twice the rate men, which is consistent with other data among middle Eastern Muslim women(Rezaeian 2010). Higher rates of suicidal behaviors have consistently been identified among women compared with men in many other countries as well (Boyd et al. 2015).
Limitations of the present study should be considered. Data collection was cross-sectional; other literature has reported longitudinal results on trauma experiences, psychiatric disorders, and suicidal behavior, however none to our knowledge in the country of Afghanistan. Building a mental health research infrastructure in the country will ensure that ongoing studies of longitudinal associations will be possible in the future. Experiences were based on self-report, as is common in psychiatric epidemiological studies, however evidence indicates that self-report of suicidal behavior is relatively reliable. Finally, the survey did not include information on all possible risk factors for suicidal behavior, including genetic vulnerability and family history. Indeed, the development of suicide risk is complex, involving contributions from biological (including genetics), psychological (such as certain personality traits), clinical (such as comorbid psychiatric illness), social and environmental factors (Turecki et al. 2019). The complexity of suicidal behavior is supported by many other studies that document how suicide is influenced by the interaction of a variety of biological, clinical, psychological, social, cultural and environmental factors. As we conduct more research in the region, we plan to attend to these aspects of psychiatric disorder risk as well.