How common are suicidal ideation and attempts in Kenya, and what influences them?
Trigger warning: The following blog describes research about suicidal ideation, suicidal attempts, and suicide. Some readers may find this distressing.
It used to be commonly said, both in the West and in Africa, that suicide was a western phenomenon and that it rarely occurred in Africa. This presumption was at least partly based on figures submitted by governments to the World Health Organisation (WHO).
However, richer nations generally have had and still have much more exhaustive methods of data collection about causes of mortality based on formal death certifications of all deaths by qualified doctors, which were then reported to a national database. In low and middle income countries where doctors were and still are often few and far between, where burials are swift (generally within 24 hours) and where suicide may still be illegal, suicide reporting has generally been much less systematic. Therefore, these factors contribute to an underestimation of the numbers of death by suicide in these countries.
I am a psychiatrist and epidemiologist who has worked for some decades with governments and their ministries of health, especially in low and middle income countries, on policy development, research and training of health staff. This article describes some research into the prevalence of suicidal thoughts and attempts, and their risk factors, in a district of western Kenya.
When I first started working with ministries of health in Africa in 1997, I was puzzled by the presumption that suicide is rare, especially as I frequently heard anecdotes of what sounded like probable suicides, such as people jumping from high buildings or ferries. But then I came across a careful study of female mortality in one region of Tanzania, which found a suicide rate in women aged between 15 and 59 years old that was similar to rates in England.
Researching the Population Pathway to Suicide
When seeking to study the antecedents of actual suicide, it is useful to look at suicidal ideation and suicide attempts, partly because they are much more common than actual suicides, and partly as these are part of the pathway to suicide. These range from depressive thoughts, feeling that life is not worth living (tedium vitae), feeling one would rather be dead (death wish) to suicidal thoughts, suicidal plans and hence to suicide attempts.
So, my Kenyan colleagues and I carried out the first household population study in Kenya to look at suicidal thoughts (ideas ranging from feeling that life is not worth living and that one would rather be dead, to thoughts of wanting to kill oneself, and even to considering possible methods) and suicide attempts as part of a mental health epidemiological survey of a household population in Maseno district, near Lake Victoria in Nyanza Province in Kenya.
How Do Rates in Kenya Compare with Those in Other Countries?
We found that, at some point in their lives, over a quarter of the study participants had thought that life was not worth living (tiredness of life or tedium vitae), while over a fifth had experienced death wishes at some stage. When we compared these figures with similar albeit much larger surveys in Britain, Australia, and the United States (US), we found that suicidal ideation in this Kenyan population is a little more common than suicidal ideation in the United Kingdom (UK) and Australia, and nearly twice as common as that found in the US, meanwhile suicidal attempts in Kenya were rather more common than that found in the US but a little less common than found in the UK.
This is the first household population study in Kenya to look at suicidal ideation and suicide attempts. Previous studies have only looked at patient samples and at college students. Interestingly the studies of the Kenya college students also found higher prevalence of suicidal ideation compared to US college students.
What are the Factors Associated with Suicidal Thoughts and Attempts in Kenya?
When we looked at factors associated with suicidal thoughts in our Kenyan survey, we found that female sex, having Common Mental Disorder (CMD), having a number of recent stressful life events (such as serious illness, injury or assault to oneself or a close relative, death of an immediate family member, death of a close family friend or other relative, separation due to marital difficulties, or steady relationship breakdown, serious problem with a close friend, neighbour or relative), and having a large social group size were all associated with increased rates of lifetime suicidal thoughts.
Furthermore, when we looked at factors associated with suicidal attempts, the presence of psychotic symptoms (such as feeling happy without a break for days on end, feeling that thoughts were interfered with or controlled by someone else, feeling that people were against you, and plotting to cause serious harm, feeling that something strange was going on, and hearing voices) was found to be significantly associated, once factors such as age, sex, employment status, and life events had been taken into account.
How Does This Compare with Other Countries?
Risk factors associated with suicidal thoughts and attempts show some consistency across studies and countries. The World Mental Health Survey Initiative which studied 17 countries (including Nigeria and South Africa, but not Kenya) found that risk factors for suicidal ideation which were consistent across the selected countries included female sex, younger age, less well educated, unmarried (i.e., single, separated, divorced or widowed) and having received a diagnosis of a mental disorder. The US National Comorbidity Survey also found that higher rates were associated with being female, young age, less well educated, unmarried and unemployed. We were therefore surprised that an association between age and either suicidal ideation or attempts was not found in this Kenyan study.
Why We Might Not Have Found a Decline in Suicdal Ideation and Attempts in Older People in Kenya A detailed cohort study in the UK found that the decrease in reported previous-year suicidal thoughts with increasing age was partly explained by lower rates of reported abuse in childhood (in those older than 75), depression, and anxiety symptoms (in those older than 55), all factors which are all strongly associated with suicidal thoughts. Moreover, higher rates of homeownership and cohabitation are protective factors in people older than 35.
Interestingly, rates of phobias, irritability, and compulsions (an irresistible urge to behave in a certain way) also decreased with age, and the association of these symptoms with suicidal thoughts was particularly strong in the youngest age group (between 16 and 34 years of age). Additionally, childhood abuse looks to be a common risk factor in all age groups as people who reported experiencing childhood abuse in all age groups reported higher rates of suicidal thoughts. This suggests that childhood sexual abuse (i.e., non-consensual sexual intercourse, unwanted sexual touching, and uncomfortable sexual talk) has lifelong negative effects on suicidal ideation. So, it is possible that in our Kenyan sample, the older age groups have accumulated fewer protective factors than would be found in a Western sample.
What About the Effects of Life Events and Social Network Size?
The relationships we found between life events and suicidal ideation and attempts respectively were to be expected and are found elsewhere. However, the inverse relationship of suicidal ideation and suicide attempts with social network size in Kenya is counter-intuitive. Nevertheless, in the same survey we found a similar inverse relationship (when one variable increases, the other variable decreases and vice versa) of CMD and psychosis with social network size and perceived social support.
Similarly, a previous study in Tanzania found a relationship of CMD with three or more recent life events but no relationship with social network size or perceived social support; and a relationship of psychosis with two or more recent life events, but again no relationship with social network size or perceived social support.
It may be that extended family groupings, common in Africa, and hence network size, confer obligations as well as supports, and this may account for the lack of protective effect of social network size or perceived social support found both in this study and in the earlier study in Tanzania.
This study indicates that suicidal ideation and attempts pose a significant public health burden in this poor rural area of Kenya, characterised by political unrest, high unemployment and environmental problems of drought, and water hyacinth in the Lake hampering the fishing industry. This is a local rather than a national survey and there is a need for a nationally representative mental health survey in Kenya which includes an appraisal of suicidal ideation and attempts. The findings are relevant for mental health promotion and prevention programmes, public education and professional training programmes in relevant sectors, especially in front line health workers and social workers who need regular systematic training in biopsychosocial assessment and management of suicidal risk.
Organisations which provide both resources and direct help:
distrACT — Appwhich provides information and advice about self-harm. nhs.uk/apps-library/distract
Samaritans — 116 123 (freephone); firstname.lastname@example.org; Freepost SAMARITANS LETTERS; samaritans.org
If you would like to learn more about this topic, here are a few articles that I’d recommend as helpful reading: