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Marital Status and Suicidal Behavior in South Asia: A Systematic Review and Meta-Analysis

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Abstract
The connection between marital status and suicidal behavior has been poorly assessed in South Asia. We aimed to see the proportion of marital status in individuals in suicidal behavior in South Asian countries. We followed PRISMA guidelines and registered the protocol in advance (PROSPERO 2023 CRD42023399906). A systematic search was conducted in Medline, Embase, and PsycINFO. Meta-analyses were performed to pool the proportion of married individuals with suicidal behavior (total, suicide, and suicide attempt) in South Asian countries. Our search identified 47 studies for this review from six countries published from 1999 to 2022 with a sample size ranging from 27 to 89178. The proportion of married individuals was 55.4% (95% CI 50.1-60.5) for suicidal behavior, 52.7% (95% CI 44.5 – 60.7) for suicides, and 43.1 (95% CI 32.9 – 53.9) for suicide attempts. The proportion of married persons among suicide attempts varied significantly across countries (p=0.016) which was highest (61.8%; 95% CI: 57.2 – 66.2) in India, followed by Bangladesh (52.5%; 95% CI 41.8% - 62.9%) and Pakistan (45.1%; 95% CI 30.9 – 59.9). As the current study did not assess any cause-and-effect association, a cautious interpretation is warranted while considering married marital status as a risk factor.
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Subject: Public Health and Healthcare  -   Public Health and Health Services

1. Introduction

Suicide having a linkage with human and socioeconomic losses is considered a serious public health issue. Worldwide, each year around 700,000 people lose their life by suicide (1). More than three-quarters of this loss is occurring in low- and middle-income countries (LMICs) (1), indicating the necessity of urgent attention to decrease suicidal behavior.
Suicide is the end product of a network of interactions among multiple risk factors (2). Despite mental health being one of the major risk factors for suicide, a systematic review found that psychiatric disorders had a similar population-attributable risk for suicide in terms of socioeconomic factors (3), warranting the significance of social factors for improving population health and reducing the burden of suicide. Moreover, the odds of suicide are higher during periods of socioeconomic, family, or individual crisis (2).
Among socioeconomic factors, marital status is linked with social and community integration (4), and in turn is associated with social isolation and its further consequences including suicidal behavior (5). While marriage could enhance social integration and regulation leading to chances of reducing suicidal risk, divorce, on the other hand, could increase suicide risk by breaking the marriage and relationships between the individual (4). There are several studies that have examined to demonstrate that marital status is a significant factor in suicide and have found that single people are significantly more likely to die by suicide than married people (6–12). Similarly, cultural and geographical factors are also related to developing suicidal behavior. For example, marriage acting as a protective factor is subject to culture-specific (7). Likewise, the sociocultural and economic contexts of Asian nations differ from Western nations when it comes to suicide (13–16).
A small number of studies have examined the connection between marital status and suicidal behavior in South Asia, a region with a high rate of suicide. South Asia (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) is home to one-fifth of all mental health cases and accounts for approximately 25% of the global population (17). As there is scattered evidence on suicide and marital studies in South Asian countries, we attempt to conduct a systematic review by looking at published (i.e., peer-reviewed) studies conducted in South Asian countries. As a result, we aimed to assess the proportion of marital status of individuals in suicidal behavior in South Asian countries.

2. Materials and Methods

2.1. Search Strategy

We made a systematic search in three databases (Medline, Embase, and PsycINFO) by predesigned search terms to identify available papers. We also performed hand search in previously published reviews (17–19). The search details are mention in Supplementary File S1 and the review protocol was registered in advance (PROSPERO 2023 CRD42023399906). We searched the data bases from inception to search date (February 04, 2023).

2.2. Inclusion Criteria

We included original research contributions, studies with quantitative estimates, published in the English language, and articles available in full-text were included. The population included in this review was restricted to studies in South Asian countries (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka) in humans. Only studies mentioning marital status of persons with suicidal behavior i.e. suicide, suicide attempt, or both (fatal and/or non-fatal suicide attempts irrespective suicidal intent) were included.

2.3. Exclusion Criteria

We excluded articles discussing the effects among veterans, and articles with only qualitative outcomes. We also excluded any type of review, editorial, erratum, letters without primary data, and multiple articles from same projects. In such cases, we included the paper providing the data in maximum extent regarding marital status and suicidal behavior was included.

2.4. Study Selection

The studies were independently screened by two review authors (SMYA, VM) and a third review author (RK) was consulted when needed. We followed PRISMA flow chart and mentioned the stepwise details of the search in Supplementary File S2.

2.5. Data Extraction

We extracted the study details (name of the lead author, year of publication, name of the journal), country where the study was conducted, place where the study was conducted, instruments measuring suicidal behavior, duration of the study, data collection year, study design, data collection methods, study setting (rural/ urban), sample size, male-female ratio (when applicable), type of suicidal behavior (attempt/suicide/both), and marital status. We considered the marital status in two groups (married and others [never married/unmarried, separated, widow/widower]). Data were extracted by two review authors (DB & KM) independently in Microsoft Excel version 10 and a third review author was involved (RS) when necessary and checking.

2.6. Quality Assessment

Among the included articles, the cross-sectional studies’ methodological quality as assessed by using Newcastle Ottawa Scale (NOS) that was adapted for the cross-sectional studies (20). The methodological quality of the case control studies was assessed by using Newcastle Ottawa Quality Assessment Scale for case control studies (21). Two authors (MH and SMYA) independently assessed the risk of bias of included studies. For cross-sectional studies, the NOS scale is assessed on three domains: (1) sample selection, (2) comparability of the different outcome groups, and (3) outcome assessments and statistical analysis. While for case control studies, (1) selection of cases and controls, (2) comparability, and (3) exposure domains were assessed for methodological quality. In both scales, the total score was summed up and evaluated as low risk of bias (7 and above), moderate risk of bias (4 to 6) and high risk of bias (3 and below).

2.7. Data Analysis

RStudio (version 2023.06.0+421) and statistical package meta were used for meta-analysis. The proportion of married individuals (with 95% Confidence Interval [CI]) in total suicidal behavior, suicide attempts and suicide was pooled using both fixed and random effects models. The heterogeneity among studies was explored using both the Cochran’s Q and the I2 statistic. Subgroup analysis was carried out across type of suicidal behavior (fatal and non-fatal), country (i.e., Bangladesh, India, and Pakistan), and study quality (low, moderate, and high). Groups with less than three studies were omitted from the sub-group analysis to avoid distorted and non-generalizable estimates. The random effect estimates were used because of high heterogeneity among studies. A prediction interval was also estimated to provide a range of expected prevalence of married individuals among suicide cases. Publication bias was not assessed as the assumption that positive results are preferentially published is not necessarily true for proportional studies (22).

3. Results

3.1. Characteristics of Included Studies

Our search identified 47 studies for this review from six countries (Bangladesh [8], India [27], Nepal [1], Pakistan [9], and Sri Lanka [2] (Table 1). We did not find any studies from Bhutan and the Maldives. Studies were published between 1999 and 2022 (Table 1). Suicide was the outcome variable in 30 studies, suicide attempt was found in 8 studies, and the rest of the studies include suicidal behavior (suicide and suicide attempt). Sample size ranges from 27 to 89178. 23 studies were conducted in urban settings, 7 were in rural areas and the 17 studies had mixed samples from both urban and rural areas. Data were collected by interview in 32 studies and different records were reviewed in the rest studies.

3.2. Study Quality Assessment

As per modified Newcastle Ottawa Quality assessment scales for cross-sectional study and case-control study, six studies (n=6, 12.76%) had high quality, thirty-six studies (n=36, 76.60%) had moderate quality, and five studies (n=5, 10.64%) had poor quality. Among 38 cross-sectional studies, (1) the majority of the included studies’ (34/38, 90%) sample were selected by non-random sampling methods, 7/38 (18%) studies used validated questionnaire tools, while 27/38 (71%) studies described the questionnaire tool although the validation was not clearly mentioned. Regarding the comparability of the different outcome groups, only 3/38 (8%) studies controlled for the important confounding factors. In the outcome assessments and statistical analysis domain, 22/38 (58%) studies collected self-reported data, while the other studies used independent blind assessment and record linkage. 32/38 (84%) studies clearly described the statistical tests (Supplementary file S3, Appendix Table 1). Among the included 9 case-control studies, all the studies (9/9, 100%) clearly mention and applied the valid method for the selection of case, 8/9 (89%) studies selected community control, 7/9 (78%) studies controlled for the confounders. While the exposure was measured by semi-structured interviews or psychological autopsy in all the studies (9/9, 100%) (Supplementary File S3, Appendix Table 2).

3.3. Marital Status in Suicidal Behavior

The proportion of married individuals among persons with suicidal behavior was 55.4% (95% CI 50.1-60.5; 47 studies; n=105585; I2= 96.9%, Figure 1). The prediction interval of proportions ranged from 23.2-83.6%. The studies by Sadia et al. (61), Arafat et al. (29), Arafat et al. (30), Arafat et al. (31), Saaiq & Ashraf (63) and Reza et al. (60) reported both fatal and non-fatal suicidal behavior but did not specify how many subjects had fatal and non-fatal behaviors. On the other hand, the studies by Ahmed et al. (25), Sharmin Salam et al. (66) and Bhatia et al (39) also reported both types of behaviors and specified their numbers. Hence, for subgroup analysis, between fatal and non-fatal suicide behavior the former six studies were excluded and the latter three studies were divided into two parts (fatal & non-fatal). The subgroup analysis (Figure 2) revealed that among proportion of married individuals was 52.7% (95% CI 44.6–60.7; 33 studies; n=102602; I2=97.8%) in suicides and 43.1 (95% CI 32.9 – 53.9; 11 studies; n=2902; I2=96.6%) in non-fatal attempts. The prediction intervals were 14.7–87.8% and 14.8–76.8%, respectively. However, the difference was not significant (p=0.128) (Table 2).

3.4. Country-wise Variation

The proportion of married persons among attempted suicide cases varied significantly across countries (p=0.016, Table 2). Studies in India found the highest proportion (61.8%; 95% CI: 57.2 – 66.2; n=101443; I2= 94.6%) followed by Bangladesh (52.5%; 95% CI 41.8-62.9%; n=2013; I2=89.0%) and Pakistan (45.1%; 95% CI 30.9–59.9; n=1649; I2=93.2%). Prediction interval were 38.6– 80.6% for India, 23.5– 79.9% for Bangladesh and 11.1–84.3% for Pakistan (Figure 3).
The pooled proportions did not differ significantly in relation to quality of the studies (p=0.63, Table 2). The proportion estimates were 54.4% (95% CI 38.3–69.7; 5 studies; n= 1133; I2=83.5%) for low quality studies, 56.4% (95% CI 50.1– 62.5; 36 studies; n=100899; I2=96.9%) for medium quality studies and 50.1% (95% CI 35.4–64.8; 6 studies; n=3553; I2= 91.4%) for high quality studies. The prediction intervals were 18.2-86.3%, 22.3-85.3%, and 15.9– 84.2% respectively (Figure 4).
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Figure 3. A forest plot showing proportion of married individuals with suicidal behavior across countries.
Figure 3. A forest plot showing proportion of married individuals with suicidal behavior across countries.
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Figure 4. A forest plot showing the proportion of married individuals with suicidal behavior stratified by study quality.
Figure 4. A forest plot showing the proportion of married individuals with suicidal behavior stratified by study quality.
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Table 1. Distribution of studies (n=47).
Table 1. Distribution of studies (n=47).
SN Study Country Place of study Study duration (month) Data collection year Data Collection Methods Study setting Sources of cases Suicidal behavior Method Number of cases Male Female Age of respondents (Years) Mean (SD)
1 Abdullah et al., 2018 (23) Pakistan Khyber Pakhtunkhwa 8 2015 psychological autopsy interviews urban hospital fatal mixed 63 38 25 22.10+3.08
2 Acherjya et al., 2020 (24) Bangladesh Jashore 6 2018 interview urban hospital fatal poisoning 474 223 251 27±11
3 Ahmad et al., 2017 (25) Pakistan Karachi 60 2011-2015 record review and interviews urban police records and poison centre both mixed 700 450 250 28.19± 8.79 in male, 26.07±8.25 years in female
4 Ali et al., 2022 (26) Pakistan Punjab 48 2018-2021 interview Urban Community fatal mixed 100 60 40 26
5 Ambade et al., 2007 (27) India Maharashtra 36 1998-2000 record review urban mortuary data and police records fatal mixed 1127 704 423
6 Ambade et al., 2015 (28) India Maharashtra 60 2001-2005 record review rural police and autopsy records fatal hanging 127 107 20 10-80 years
7 Arafat et al., 2020 (29) Bangladesh 12 2018-2019 reviewing online news reports both community both mixed 199 94 105 26.86±13.60
8 Arafat et al., 2020 (30) Bangladesh 12 2018-2019 reviewing of print news reports both community both mixed 403 179 224 25.81±11.62
9 Arafat et al., 2021 (31) Bangladesh Dhaka 13 2019-2020 interviews urban community fatal mixed 100 49 51 26.30 ±12.36
10 Arafat et al., 2018 (32) Bangladesh 120 2009-2018 reviewing online news content both community both mixed 358 142 215 23.84±11.42
11 Armstrong et al., 2019 (33) India Tamil nadu 7 2016 reviewing print news papers both Community fatal mixed 988 467 521
12 Badiye et al., 2014 (34) India Maharastra 60 2009-2013 record review urban Records from crime branch fatal mixed 2306 1647 659
13 Bansal et al., 2011 (35) India Punjab 12 2010 interview urban hospital non-fatal mixed 100 61 39 26.98 ±8.13
14 Bashir et al., 2014 (36) Pakistan Karachi 6 interview urban hospital non-fatal poisoning 374 230 144 25 ±10.1
15 Bastia & Kar, 2009 (37) India Cuttack 24 1998-1999 interview and record review urban Community fatal hanging 104 43 61 28.7 ±11.4
16 Bhatia et al., 2006 (38) India Delhi 60 reviewing suicide notes and interviews urban Forensic data fatal mixed 40 26 14
17 Bhatia et al., 2000 (39) India Delhi record review, interviews urban hospital Both mixed 373 189 184
18 Bhise and Behere, 2016 (40) India Maharashtra 18 2008-2009 interview rural community people fatal mixed 98 88 10
19 Chandrasekaran & Gnanaselane, 2005 (41) India Puducherry 12 2001-2002 interview mixed hospital non-fatal mixed 341 153 188 26.1±9.3
20 Chaudhari et al., 2022 (42) India Puducherry 60 2010-2014 record review both Forensic records fatal poisoning 595 363 232 35.8 +14.6
21 Fernando et al., 2010 (43) Sri Lanka Colombo 12 2006 interview urban court records fatal mixed 151 93 58
22 Hagaman et al., 2017 (44) Nepal Nepal 4 2015-2016 interview and reviewing police records both community fatal mixed 302 172 130 32.9+17.55
23 Halder & Mahato, 2016 (45) India Kolkata 24 2013-2014 interview urban hospital non-fatal mixed 100 28 72 23.51 ± 6.38
24 Kar, 2010 (46) India Orissa 24 1994-1996 interview urban hospital non-fatal mixed 149 65 84 31.6 ±13.5 years
25 Khan et al., 2005 (47) India Secunderabad 1 2005 interview both hospital fatal mixed 50 29 21
26 Khan et al., 2008 (48) Pakistan Karachi 12 2003 interview, psychological autopsy method urban community people fatal mixed 100 83 17
27 Khan et al., 2009 (49) Pakistan Ghizer 48 2000-2004 Police records and Interview Urban Police records fatal mixed 49 49
28 Kumar et al., 2015 (50) India Lucknow 60 2008-2012 record review both hospital fatal burning 857 66 791 33.74 ± 11.64
29 Kumar & Hashim, 2017 (51) India Karnataka 36 2013 - 2015 record review rural hospital fatal mixed 426 355 71 34.7
30 Kumar et al., 2011 (52) India Kerala 6 2004 Interview rural community fatal mixed 166 124 42 40.45+17.07
31 Manoranjitham et al., 2010 (53) India Tamil Nadu 20 2006-2008 psychological autopsy interview rural community fatal mixed 100 59 41 42.24 ±20.69
32 Mayer & Ziaian, 2002 (54) India 1995 record review both community sample fatal mixed 89178 52357 36821
33 Mohanty et al., 2007 (55) India Berhampur 48 2000-2003 record review, interviews both hospital fatal mixed 588 300 288
34 Naz, 2016 (56) Pakistan Punjab 10 2014-2015 reviewing newspaper content both community people fatal mixed 87 50 37
35 Pal et al., 2022 (57) India Madhya Pradesh 12 2020-2021 interview Urban hospital non fatal mixed 60 38 22 39.03±11.58
36 Parkar et al., 2009 (58) India Mumbai 84 1997-2003 Interview urban slums community people fatal mixed 76 33 43
37 Patel et al., 2012 (59) India 36 2001-2003 Interview both community sample fatal mixed 2684 1393 964
38 Reza et al., 2013 (60) Bangladesh 24 interview rural hospital both mixed 113 44 69 29.6±12.8
39 Sadia et al., 2021 (61) Pakistan Sargodha 12 2019 record review both hospital both wheatbill (aluminium phosphide) 83 42 41
40 Sahoo et al., 2016 (62) India Jamshedpur 6 2013–2014 interview both hospital non-fatal mixed 101 42 59
41 Saaiq & Ashraf, 2014 (63) Pakistan Islamabad 24 2010 - 2012 interviews and record review both hospital both burning 93 18 75 26.89±6.1
42 Samaraweera et al., 2008 (64) Sri Lanka Ratnapura 3 interviews, psychological autopsy urban community people fatal mixed 27 19 8 43
43 Shah et al., 2017 (65) Bangladesh 6 2016-2017 reviewing print news reports both community fatal mixed 271 113 158 26.67 ± 13.47
44 Sharmin Salam et al., 2017 (66) Bangladesh 4 sub-districts 6 2013 interview rural Community both mixed 95 48 47
45 Srivastava, 2013 (67) India Goa 36 2005-2007 record review and interviews urban community fatal mixed 100 70 30
46 Vijayakumar & Rajkumar, 1999 (68) India Chennai 14 1994-1995 interviews, and record review urban community fatal mixed 100 55 45
47 Vijayakumar et al., 2008 (69) India Chennai 23 2002-2003 Interview urban hospital non fatal 509 244 265 25.85±9.28
Table 2. Statistical comparison of pooled proportions of married individuals with suicidal behavior across different subgroups.
Table 2. Statistical comparison of pooled proportions of married individuals with suicidal behavior across different subgroups.
Subgroups Pooled proportions 95%CI I2 Psubgroup
Fatality 0.13
Fatal (k=33) 0.53 0.45 – 0.61 97.8%
Nonfatal (k=11) 0.43 0.33 – 0.54 96.6%
Country 0.0155
Pakistan (k=9) 0.45 0.31 – 0.59 93.2%
Bangladesh (k=8) 0.52 0.42 – 0.63 89.0%
India (k=27) 0.62 0.57 – 0.66 94.6%
Quality 0.6328
Low (k=5) 0.54 0.38– 0.69 83.5%
Moderate (k=36) 0.56 0.38 – 0.69 96.9%
High (k=6) 0.51 0.35 – 0.65 91.4%

4. Discussion

4.1. Major Findings of the Study

The aim of this systematic review was to determine the proportion of marital status in individuals with suicidal behavior (fatal, non-fatal, or both) in South Asian countries. By analyzing a total of 47 studies, we found several key findings that shed light on this relationship between marital status and suicidal behavior. Our analysis revealed that the proportion of married individuals among persons with suicidal behavior in South Asia was 55.4%. This finding suggests that marital status may play a significant role in suicidal behavior in this region. However, it is important to note the high heterogeneity among studies included in our review. This indicates that there is considerable variability in the estimates across studies, which may be attributed to differences in sample characteristics, study designs, and measurement instruments.
When examining the specific types of suicidal behavior, our subgroup analysis showed that the proportion of married individuals among suicides was 52.7%, while among non-fatal suicide attempts it was 43.1%. Although the difference between these two groups was not statistically significant, these findings suggest that marital status may have varying degrees of association with different forms of suicidal behavior. Further research is needed to explore this association in more depth and investigate potential underlying factors.
Our analysis did not find a significant difference in the proportion of married individuals among persons with suicidal behavior based on the quality of the studies. This suggests that the association between marital status and suicidal behavior is consistent across studies with varying methodological quality. However, it is worth noting that the majority of the included studies were of moderate or poor quality, indicating the need for more rigorous research in this area.

4.2. Implications of the Study Results

Our findings have two important implications. Firstly, the relationship between marital status and suicidal behavior in South Asia appears to exhibit unique patterns compared to findings elsewhere. In many Western countries, being unmarried or divorced is often associated with a higher risk of suicidal behavior, while being married is generally considered protective (4,70). However, studies in South Asia have shown a higher proportion of married individuals among those engaging in suicidal behavior (59,68,71-73). This contrasting finding suggests that the association between marital status and suicidal behavior may be influenced by cultural, social, and economic factors specific to the South Asian region. Specifically, gender stereotyping, limited agency for women, and the expectation of fulfilling certain marital responsibilities may contribute to stress and psychological distress within marriages, potentially increasing the risk of suicidal behavior among married individuals, particularly among women (59,68).
Secondly, we also observed significant country-wise variation in the proportion of married individuals among attempted suicide cases. Studies conducted in India reported the highest proportion (61.8%), followed by Bangladesh (52.5%) and Pakistan (45.1%). These findings indicate that cultural and social factors may moderate the association between marital status and suicidal behavior in South Asian countries. Context-specific factors such as gender roles, societal norms, and marital expectations, which may differ between settings, could contribute to these variations.

4.3. Strength and Limitations

To the best of the authors’ knowledge, this is the first study assessing the marital status in suicidal behavior in South Asia. However, the present systematic review had some key limitations. First, the analysis may not reflect marital status as a risk factor as these findings may justify the proportion of married persons in the community. Second, the high heterogeneity among the included studies in terms of study design, populations, and measurement tools may have influenced pooled estimates and may affect the generalizability of results. Third, the potential for publication bias was not assessed due to the nature of studies included in this review. Fourth, the reliance on self-reported data in some studies may introduce biases and affect the accuracy of the estimates. Fifth, because we included only studies done on patients with suicidal behavior, we were unable to estimate associations between different types of marital status and suicidal behavior in the region.

5. Conclusions

This systematic review provides insights into the association between marital status and suicidal behavior in South Asia. The findings suggest that marital status may play a role in suicidal behavior, but further research is needed to better understand the underlying mechanisms and contextual factors. Future studies should consider employing standardized methodologies and addressing the limitations identified in this review to enhance the robustness of the evidence. Understanding the association between marital status and suicidal behavior can inform the development of targeted interventions and support strategies aimed at reducing suicide rates in South Asia.

Supplementary Materials

The following supporting information can be downloaded at the website of this paper posted on Preprints.org. Supplementary File S1, S2, S3.

Author Contributions

Conceptualization, S.M.Y.A. methodology, S.M.Y.A., and V.M. software, M.A.S.K. validation, S.M.Y.A.; formal analysis, M.A.S.K., and Y.K.; investigation, S.M.Y.A.; resources, S.M.Y.A., and V.M.; data curation, S.M.Y.A., R.S., D.B. and K.M.; writing—original draft preparation, S.M.Y.A., V.M., M.A.S.K., M.N.N.H., R.S., D.B., Y.K., and K.M.; writing—review and editing, S.M.Y.A., V.M., M.A.S.K., M.N.N.H., R.S., D.B., Y.K., and K.M.; visualization, M.A.S.K.; supervision, S.M.Y.A.; project administration, S.M.Y.A.; All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Ethical review and approval were waived for this study due to we reviewed publicly available articles.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author.

Acknowledgments

None.

Conflicts of Interest

The authors declare no conflict of interest.

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Preprints 79258 g001
Figure 1. A forest plot showing the proportion of married individuals among all suicidal behavior.
Figure 1. A forest plot showing the proportion of married individuals among all suicidal behavior.
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Figure 2. A forest plot showing the overall proportion of married individuals among suicide and suicide attempts.
Figure 2. A forest plot showing the overall proportion of married individuals among suicide and suicide attempts.
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