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Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: a systematic review and meta- analysis
Open accessAbstract
BACKGROUND: Psychiatric disorders are reported to be present in 80% to 90% of suicide deaths in high-income countries (HIC), but this association is less clear in low- and middle-income countries (LMIC). There has been no previous systematic review of this issue in LMIC. The current study aims to estimate the prevalence of psychiatric morbidity in individuals with suicidal behaviour in LMIC. METHODS AND FINDINGS: PubMed, PsycINFO, and EMBASE searches were conducted to identify quantitative research papers (any language) between 1990 and 2018 from LMIC that reported on the prevalence of psychiatric morbidity in suicidal behaviour. We used meta-analytic techniques to generate pooled estimates for any psychiatric disorder and specific diagnosis based on International classification of disease (ICD-10) criteria. A total of 112 studies (154 papers) from 26 LMIC (India: 25%, China: 15%, and other LMIC: 60%) were identified, including 18 non-English articles. They included 30,030 individuals with nonfatal suicidal behaviour and 4,996 individuals who had died by suicide. Of the 15 studies (5 LMIC) that scored highly on our quality assessment, prevalence estimates for psychiatric disorders ranged between 30% and 80% in suicide deaths and between 3% and 86% in those who engaged in nonfatal suicidal behaviour. There was substantial heterogeneity between study estimates. Fifty-eight percent (95% CI 46%-71%) of those who died by suicide and 45% (95% CI 30%-61%) of those who engaged in nonfatal suicidal behaviour had a psychiatric disorder. The most prevalent disorder in both fatal and nonfatal suicidal behaviour was mood disorder (25% and 21%, respectively). Schizophrenia and related disorders were identified in 8% (4%-12%) of those who died by suicide and 7% (3%-11%) of those who engaged in nonfatal suicidal behaviour. In nonfatal suicidal behaviour, anxiety disorders, and substance misuse were identified in 19% (1%-36%) and 11% (7%-16%) of individuals, respectively. This systematic review was limited by the low number of high-quality studies and restricting our searches to databases that mainly indexed English language journals. CONCLUSIONS: Our findings suggest a possible lower prevalence of psychiatric disorders in suicidal behaviour in LMIC. We found very few high-quality studies and high levels of heterogeneity in pooled estimates of psychiatric disorder, which could reflect differing study methods or real differences. There is a clear need for more robust evidence in order for LMIC to strike the right balance between community-based and mental health focussed interventions.
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“These syndromes constitute a risk factor for subsequent onset of depression, and may be the sequelae of partial remission of an episode of major depression. 173”
From Time for united action on depression: a Lancet–World Psychiatric Association Commission (2022) · cites this paper as [173]
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“some of the key drivers of recent trends in suicide rates differ between low- and high-income countries, for example the prevalence of underlying mental health problems in the population (Knipe et al., 2019).”
From Social media use, economic recession and income inequality in relation to trends in youth suicide in high-income countries: a time trends analysis (2020) · cites this paper as Knipe et al., 2019
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“Suicide is a leading contributor to global mortality and three-quarters of these deaths occur in low- and-middle-income countries (LMIC) (Iemmi et al., 2016; Knipe et al., 2019; WHO, 2017).”
BackgroundOngeri, L., Theuri, C., Nyawira, M., Penninx, B. W. J. H., Tijdink, J. K., Kariuki, S. M., & Newton, C. R. J. C. (2023) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2023.152382 · Cited by 12
Vitamin D and suicidality: a Chinese early adolescent cohort and Mendelian randomization study
Yuan, M., Li, Y., Chang, J.-J., Zhang, X., Wang, S., Cao, L., Li, Y., Wang, G., & Su, P. (2023) · Epidemiology and Psychiatric Sciences · doi:10.1017/s2045796023000665 · Cited by 10
“Mood disorders, anxiety disorders and substance misuse are the most prevalent psychiatric morbidities in individuals with suicidality (Knipe et al., 2019).”
BackgroundRisk factors of suicidal behaviors in a high‐risk longitudinal veteran sample: A network analysis
Saulnier, K. G., Volarov, M., Velimirović, M., Bauer, B. W., Kolnogorova, K., Ashrafioun, L., Stecker, T. A., & Allan, N. P. (2022) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.12918 · Cited by 8
Staniszewska, A., Lasota, D., Kielan, A. J., & Brytek‐Matera, A. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19042343 · Cited by 8
“They are often described as an “external cause of death,” which is imprecise and untrue [4].”
BackgroundBasnet, A., Shrestha, D. B., Chaulagain, S., Thapa, A., Khadka, M., Regmi, B., Khadka, M., Adhikari, K., Thapa, A. J., Pokharel, S., et al. (2021) · F1000Research · doi:10.12688/f1000research.54327.2 · Cited by 8
Trend and Geographical Distribution of Suicide Research: A Bibliometric Analysis of Three Decades
Arafat, S. M. Y., Singh, R. K., Singh, K., & Amin, R. (2024) · International Journal of Mental Health and Addiction · doi:10.1007/s11469-024-01251-x · Cited by 8
“…seem to be less prevalent among those who die by suicide in LMICs where acute life stresses related to socioeconomic and cultural issues have been shown to play a more significant role in suicide than they do in Western countries (Arafat et al., 2022; Knipe et al., 2019; Milner et al., 2013).”
Sex education and self-poisoning in Sri Lanka: an explorative analysis
Crowley, G., Bandara, P., Senarathna, L., Malalagama, A. S., Gunasekera, S., Rajapakse, T. N., & Knipe, D. W. (2022) · BMC Public Health · doi:10.1186/s12889-021-12374-4 · Cited by 8
Self-citationSocial and Psychiatric Factors of Suicidal Thoughts and Behaviors in Mozambican Adolescents
Come, A. X., Polanco-Roman, L. A., dos Santos, P. F., Fumo, W., Mutemba, R., Pathare, S., Wainberg, M. L., Oquendo, M. A., Duarte, C. S., Mello, M. F., et al. (2022) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2022.03.032 · Cited by 8
Suicide among psychiatric patients who migrated to the UK: a national clinical survey
Tham, S.-G., Hunt, I. M., Turnbull, P., Appleby, L., Kapur, N., & Knipe, D. W. (2023) · EClinicalMedicine · doi:10.1016/j.eclinm.2023.101859 · Cited by 8
Self-citationItua, I., Shah, K., Galway, P., Chaudhry, F., Georgiadi, T., Rastogi, J., Naleer, S., & Knipe, D. W. (2024) · Archives of Suicide Research · doi:10.1080/13811118.2024.2322144 · Cited by 8
Self-citationKoçak, O., Kovan, A., Alkhulayfi, A. M. A., Alshehri, N. A., Demirdöven, M., & Yıldırım, M. (2025) · BMC Psychology · doi:10.1186/s40359-025-02892-w · Cited by 9
“Based on these explanations, suicidal ideation is a globally prevalent phenomenon, and although rates vary by region, research shows that low-and middle-income societies report higher rates of suicidal ideation than those with higher socioeconomic status [27, 61].”
Roza, T. H., Marchionatti, L. E., Gosmann, N. P., do Canto, G. C., Machado, P. V., Massuda, R., Passos, I. C., Kessler, F. H. P., Magalhães, P. V. D. S., & Telles, L. E. D. B. (2023) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.13009 · Cited by 7
Cultural Perspectives of Suicide in Bangladesh
Khan, A. R. (2023) · Springer eBooks · doi:10.1007/978-981-95-8321-8_4 · Cited by 8
Deliberate Self-poisoning due to Plant Toxins: Verdant Footprints of the Past into the Present
Gunasekaran, K., Abhilash, K. P. P., Rabbi, A. S., Pradeeptha, S., & Pradeep, R. (2021) · Indian Journal of Critical Care Medicine · doi:10.5005/jp-journals-10071-23784 · Cited by 7
“Indian J Psychiatry 2016;58(3):301–306.”
Skrivankova, V. W., Rabie, S., Tlali, M., Folb, N., Chinogurei, C., Bennett, S., Wesso, A., Ruffieux, Y., Cornell, M., Seedat, S., et al. (2025) · PLoS Medicine · doi:10.1371/journal.pmed.1004765 · Cited by 8
Tu, L., Liu, Y., Zhu, H., Zhang, Q., & Xiao, J. (2024) · BMC Public Health · doi:10.1186/s12889-024-19095-4 · Cited by 8
“Additionally, a meta-analysis focusing on low-and middle-income countries suggests that only 45% of individuals engaging in nonfatal suicidal behaviors have a diagnosed psychiatric disorder [45].”
BackgroundSaeed, G., Mumtaz, S., Tanveer, J., Hamid, E., Jehan, S., Atiq, M., Kanwal, M., Sikander, S., Atif, N., Rahman, A., et al. (2024) · SSM - Mental Health · doi:10.1016/j.ssmmh.2024.100356 · Cited by 6
Song, I., & Luan, H. (2022) · Applied Geography · doi:10.1016/j.apgeog.2022.102664 · Cited by 7
Bhattacharjee, B., Roy, S., Alam, M. M., Royle, R. K. S., Paul, S., Islam, M. S., Bari, M. S., & Chowdhury, F. R. (2023) · Cureus · doi:10.7759/cureus.39893 · Cited by 6
“also found a low prevalence of psychiatric disorders in suicidal tendency in low- and middleincome countries (an average of 45% in non-fatal suicidal tendency and 55% in those who died by suicide) compared to high-income countries (80%-90%) [29].”
ResultEncina, E. P., Rodante, D., Agrest, M., Tapia‐Muñoz, T., Vidal-Zamora, I., Ardila-Gómez, S. E., Alvarado, R., Leiderman, E. A., & Reavley, N. J. (2023) · BMC Psychiatry · doi:10.1186/s12888-023-05417-0 · Cited by 8
Donnelly, H. K., Richardson, D., & Solberg, V. S. H. (2023) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.13032 · Cited by 5
Lasota, D., Mirowska-Guzel, D. M., & Goniewicz, K. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18094936 · Cited by 6
“They are often described as “external cause of death,” which is imprecise and untrue [13,53].”
BackgroundInfluentialBasnet, A., Shrestha, D. B., Chaulagain, S., Thapa, A., Khadka, M., Regmi, B., Khadka, M., Adhikari, K., Thapa, A. J., Pokharel, S., et al. (2021) · F1000Research · doi:10.12688/f1000research.54327.1 · Cited by 6
Jiang, Y., Jin, Y., Bao, J., Wang, S., Lai, W.-D., Wen, C., Xu, Z., & Yu, J. (2021) · Frontiers in Pharmacology · doi:10.3389/fphar.2021.708517 · Cited by 6
Mashhood, A., Saeed, G., & Sami, F. (2025) · SSM - Mental Health · doi:10.1016/j.ssmmh.2025.100433 · Cited by 7
Rethinking suicide prevention: insights from the global south for a new global agenda
Machado, D. B. (2025) · Nature Mental Health · doi:10.1038/s44220-025-00491-7 · Cited by 7
“In HICs, it is estimated that 80–90% of suicides are associated with a psychiatric diagnosis 29,57 , whereas in LMICs, only 58% of individuals who die by suicide meet criteria for a diagnosable mental disorder 58 .”
Suicide variations between English neighbourhoods over 2017-21: The role of spatial scale
Congdon, P. D. (2024) · Social Science & Medicine · doi:10.1016/j.socscimed.2024.117414 · Cited by 5
Pharmacological Strategies for Suicide Prevention Based on the Social Pain Model: A Scoping Review
Rajkumar, R. P. (2022) · Psych · doi:10.3390/psych4030038 · Cited by 5
Khatri, M. A., Al‐Huseini, S., Al-Maqbali, M., Cucchi, A., Saadi, A. A., Farsi, A. A., Jose, S., Al‐Sibani, N., & Al‐Adawi, S. (2023) · Journal of Psychiatric Practice · doi:10.1097/pra.0000000000000726 · Cited by 5
Sarmiento, I., Kgakole, L., Molatlhwa, P., Girish, I., Andersson, N., & Cockcroft, A. (2023) · Vulnerable Children and Youth Studies · doi:10.1080/17450128.2023.2262941 · Cited by 5
“Parenting behaviours have been associated with suicidal behaviour among youth in Africa (Randall et al., 2014; Swahn et al., 2012) and other LMIC (Kim, 2019).”
BackgroundInfluentialPalfreyman, A., Vijayaraj, K., Riyaz, S., Rizwan, Z., Sivayokan, S., Thenakoon, T. H. S., Dayabandara, M., Hanwella, R., & Devakumar, D. (2024) · Violence Against Women · doi:10.1177/10778012241230326 · Cited by 5
“Kurunegala ’ s labor emigration far exceeds Jaffna ’ s, with implications for the mental health of female migrant households and those left behind (Knipe et al., 2019).”
BackgroundTadesse, G., Gashaw, F., Amare, T., Fentahun, S., & Yitayih, S. (2024) · BJPsych Open · doi:10.1192/bjo.2024.71 · Cited by 5
Zadran, N., Kumar, J., IBRAR, A., Khan, A. W., Khan, A., Ishaq, M. S., & Tahir, A. (2020) · Cureus · doi:10.7759/cureus.10935 · Cited by 5
“Additionally, suicide rates are also increasing at an alarming rate, especially since the declaration of the COVID-19 pandemic [2-3].”
BackgroundMental health and violence against women in Afghanistan, India and Sri Lanka: a situation analysis
Quinlan-Davidson, M., Ahmad, A., Asher, L., Bhatia, U., Daruwalla, N., Devakumar, D., Nadkarni, A., Palfreyman, A., Saboor, L., Samanmalee, T. R., et al. (2025) · Global Health Research · doi:10.3310/gdom7555 · Cited by 4
Suicide risk and mental health in the general population of French Polynesia
Amadéo, S., Benradia, I., Sy, A., Rereao, M., Favro, P., David-Vanquin, G., Meunier-Tuheaiva, A., Lacoste, J., Fenni, A., Nguyen, N. L., et al. (2022) · Journal of International Medical Research · doi:10.1177/03000605221111273 · Cited by 4
Polick, C. S., Ploutz-Snyder, R. J., Braley, T. J., Connell, C. M., & Stoddard, S. A. (2023) · PLoS ONE · doi:10.1371/journal.pone.0292233 · Cited by 4
Shah, R. K., Timsinha, S., & Sah, S. K. (2021) · Journal of Nepal Medical Association · doi:10.31729/jnma.7131 · Cited by 4
Suicidal behaviour is pathological: implications for psychiatric euthanasia
Sisti, D. A., Mann, J. J., & Oquendo, M. A. (2024) · Journal of Medical Ethics · doi:10.1136/jme-2023-109522 · Cited by 3
Sinha, P., Sreeraj, V. S., Arumugham, S. S., & Thirthalli, J. (2025) · BMC Psychiatry · doi:10.1186/s12888-025-07109-3 · Cited by 3
“Up to half of the suicide deaths and non-fatal suicidal behaviours are associated with a psychiatric disorder [30].”
Hughes, A., & Pitman, A. (2026) · Crisis · doi:10.1027/0227-5910/a001044 · Cited by 4
“Neverthe-less, working with any given definition can be challenging; for example, where a systematic review is unable to separate nonsuicidal self-harm from suicide attempt because included studies lack data on intent (Knipe et al., 2019).”
Metadata
- Authors
- Knipe, D., Williams, A. J., Hannam-Swain, S., Upton, S., Brown, K., Bandara, P., Chang, S.-S., & Kapur, N.
- Affiliations
- University of Bristol (GB)
- University of Birmingham (GB)
- Sheffield Hallam University (GB)
- University of Nottingham (GB)
- Western Sydney University (AU)
- National Taiwan University (TW)
- Corresponding author
- Knipe, Duleeka
- ORCID
- Venue
- PLOS Medicine
- Publisher
- Public Library of Science (PLoS)
- Published
- 2019-10-09
- Volume
- 16
- Issue
- 10
- Pages
- e1002905
- ISSN
- 1549-1277 (ISSN-L)
- 1549-1676
- PMC
- PMC6785653
- OpenAlex
- W2980106730
- Cited by
- 174
- References
- 171
- Citations by year
- 2026: 19 · 2025: 23 · 2024: 27 · 2023: 42 · 2022: 24 · 2021: 23 · 2020: 13 · 2019: 2
- FWCI
- 2.45
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Portal (King's College London) (publishedVersion, cc-by)
- SHURA (Sheffield Hallam University Research Archive) (Sheffield Hallam University) (acceptedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Figshare (submittedVersion, cc-by)
- Bristol Research (University of Bristol) (submittedVersion, cc-by)
- Funders
- Wellcome Trust
- University of Bristol
- Elizabeth Blackwell Institute for Health Research, University of Bristol
- Topics
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Social Sciences › Sociology and Political Science › Homicide, Infanticide, and Child Abuse
- Keywords
- psychiatric morbidity, suicidal behavior, suicide, low- and middle-income countries, mood disorders, schizophrenia, anxiety disorders, substance abuse, prevalence of mental disorders, suicide mortality, ICD-10 diagnoses, India, China, South Asia, Southeast Asia, Africa, Latin America, Caribbean, Pacific Islands, Middle East
- MeSH terms
- Suicide, Completed, China, Developing Countries, Humans, India, Morbidity, Poverty, Risk Factors, Suicide, Attempted, Prevalence, Mood Disorders, Suicidal Ideation
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