Patterns of Suicide in Kuwait: a retrospective descriptive study from 2003–2009

This study was designed to investigate the patterns of suicide in the State of Kuwait.
It is the first of its type to study the different demographic parameters (age, gender,
religion, nationality and Governorate) in the reported suicides in this country. It
was of paramount importance to perform the necessary analyses to determine the basis
of the suicide problem in Kuwait. This will subsequently help the Kuwaiti Government
tackle the problem and reduce the number of suicides in the country.

The results presented in this study highlight a number of interesting details, which
will be discussed in the following account. We will also briefly discuss the rates
of suicide in other Middle Eastern Countries, mainly for comparison with our study,
as many of these countries share similar social and cultural parameters with Kuwait.

Suicide is one of the leading causes of death in the world, and suicidal attempts
constitute a major public health concern 3]. The total number of 347 cases in our study was small compared to the absolute numbers
reported from many other countries around the globe. For a country such as Kuwait
with a population of approximately 1.5 million in 2003 and 2 million in 2009, this
number is quite high.

Hanging was the leading method of suicide, while jumping from a height was the least
common method. A possible explanation is that jumping from a height constitutes a
horrible experience for the person committing suicide. Moreover, it may be viewed
and noticed by others. On the other hand, suicide by hanging has some privacy associated
with it, although the mechanism of death is complex 4].

Males outnumbered females in all methods of suicide except in jumping from a height,
for which the percentage of females was greater. Saudi Arabia shares a border with
Kuwait, and the two countries share an almost identical culture. In Saudi Arabia,
82 % of suicides were among males 5]. All victims of firearm injuries in Saudi Arabia were males. The most plausible explanation
for this observation is that gun ownership is limited to men by regulations of the
country.

The most common method of suicide in our study and in similar studies in the Middle
East is hanging 6]. In contrast, in a Scottish study, poisoning was the most preferred method of suicide
7]. Rates of suicide in most countries in the world, including Denmark, are higher among
males, which is consistent with our results 8], 9]. China is an important exception, with a very high suicide rate among females, especially
young women in rural areas 10]. However, there has been a recent trend of reduced female and increased male suicide
in China 11], 12].

The results of this study have clearly shown that all categories of suicide occurred
more frequently among the non-Kuwaiti population, except for firearm injuries. Jumping
from a height was reported exclusively among non-Kuwaiti suicide cases. Most of these
victims were housemaids who could not run away from the ill treatment of their employers.
Similar results were reported in Bahrain, another neighbouring gulf country with similar
customs and traditions to Kuwait. The mean suicide rate was 0.6 per 100,000 for Bahraini
nationals and 12.6 per 100,000 for expatriates. Indian immigrants in Bahrain demonstrated
the highest suicide rate 6]. Similarly, in Saudi Arabia, more expatriates (65.4 %) committed suicide than Saudi
citizens (36.4 %) 13].

No significant difference in suicide rates was observed between married and single
subjects. However, other studies comparing socio-demographic characteristics revealed
that a higher prevalence of suicide was associated with female gender, lower education,
poor financial perception and single marital status 14], 15].

There is limited data in the literature on the relationship between marital status
and suicidal behaviour in the Middle East 6]. A recent study from Japan concluded that single people committed suicide more often
than married people 16]. New reports in 2010 published by the Office for National Statistics in the United
Kingdom (UK) indicated that suicide rates among single and divorced subjects were
approximately three times higher than corresponding rates in married subjects of both
genders between 2000 and 2009 17]. Their results showed that 30.8 single men per 100,000 died by committing suicide
in the UK, compared to 10.6 per 100,000 married men. In the same period, 10.3 single
women per 100,000 succumbed to suicide compared to 3.6 per 100,000 married women.
The authors suggested that single people of either gender are more vulnerable to depression
than married people.

Farwania Governorate ranked first in suicide prevalence followed by Ahmady, Jahra,
the Capital, Hawally and Mubarak Al-Kabeer. The Farwania and Ahmady Governorates are
heavily populated with expatriate labourers who work at factories and cleaning companies.
These Governorates have many buildings where apartments are sublet by tenants in order
to earn more money or cover their own expenses. These areas are therefore overcrowded
and difficult to monitor by authorities. As a result, suicides are higher in these
Governorates. Data provided by the MOI in March 2010 revealed that the Farwania and
Ahmady Governorates have high crime rates 18]. Many individuals who live in these Governorates possibly retaliate by committing
crimes or become part of a criminal gang to gain extra income. It is now well known
that these depressed areas in Kuwait are a true fortress for many organized crimes,
and as a result, many people are stressed and under severe pressure due to gang crimes.
Depression and stress are forerunners of suicide.

Significantly more people in our study committed suicide in their prime and productive
years of life compared to other periods. Approximately 71 % were between the ages
of 20 and 39. The extreme age categories were the least vulnerable to suicide, with
a prevalence of 5.7 % in the under 19 group and 2.9 % in those over 60. Similar results
were found in India, where studies have highlighted that the most common age group
of suicide victims was 21–30 14], 15]. In contrast, in the United States of America (USA), a study in 2009 showed that
suicide was the third leading cause of death for young people between the ages of
15 to 24 19], 20].

Traditionally, poison (poisoning) has been one of the most commonly used substances
for suicide and homicide. In our study, suicide due to poisoning was the third most
common suicide modality. A study conducted in Egypt revealed that female adolescents
are at a higher risk of self-poisoning 21]. Deliberate self?harm is a major problem in the developing world; widespread availability
and easy access to poisons make it easier for the vulnerable to commit suicide 22]. This situation is quite often found in cases of drug overdose, which is another
method of committing suicide 23]. A study was conducted in an addiction treatment centre in a psychiatric hospital
in Kuwait to review cases of poisoning in order to identify the main poisons used
for self?harm in this region 24]. The results showed that pesticides were the most prevalent type used, followed by
paracetamol (acetaminophen). Both of these products are readily available in any grocery
store.

In 2009, the government of Kuwait reported that most cases of attempted suicide were
by ingestion of pesticides or paracetamol (acetaminophen) 25]. These drugs have become the most popular method of self?harm due to their ready
availability in residential areas, especially among people from the Bangladeshi community
who live in Kuwait. In India, medicines such as benzodiazepines and antidepressants
were those most commonly used by victims of self-poisoning 14], 15]. The previous data provide strong evidence to support the restriction of some drugs
that are easily available over the counter in shops and in supermarkets to combat
the blatant abuse that can lead to suicide 26], 27].

Suicide by firearm injuries was uncommon in our study. Guns are one of the most effective
means for committing suicide and are a far more prevalent suicide method than drug
overdose, strangulation or cutting oneself in the USA 28]. Given the high rate of gun ownership in the USA, it is logical to expect a direct
link between increased access to guns and a high incidence of suicide. However, international
data show that higher levels of gun ownership do not always correlate with higher
levels of suicide 29]. For example, personal gun ownership is more prevalent in Switzerland than in the
USA, but suicide rates are higher in the USA 30]. The actual chain of events leading to selection of a firearm as a means of death
is unclear. In fact, there are some mediating factors that contribute to firearm suicide.
People consider suicide by firearm as an honourable and quick way to eliminate personal
troubles and disappointments. Easy access to dangerous weapons is also an important
risk factor. Many Kuwaitis have guns in their possession as a result of the gulf war
in 1990, and many campaigns are spearheaded by the MOI to collect weapons that are
in the possession of residents and citizens without a valid permit.

Table 4 compares suicide rates in the Arabian Gulf and selected Arab and Middle eastern countries
in the year 2002 31]. Kuwait had one of the highest rates in the region. The suicide rate in Kuwait has
increased from 3.2/100,000 in 2002 to 6.1/100,000 in 2010 31], while the rate fluctuated between these two values throughout the period of the
study. The literature has limited reports on suicide in the Middle East. However,
the 2002 rates according to the WHO website (http://apps.who.int/en/) are similar to the rates observed during the study period (2003–2009). Reports of
the suicide rate in Bahrain in 1988 show similar values to that in Kuwait (5.4/100,000)
31] and have increased in 2012 to reach 8.1, according to the WHO website. Most Arabic
families of suicide victims would never admit the actual cause of death to anyone
and always state that their son or daughter died suddenly. Moreover, due to the negative
views that the general population has against autopsies, many suicides probably do
not reach the forensic office, as families will try and bury their loved ones quickly
and are compassionately given death certificates from authorities without the word
‘suicide’ written anywhere. Saudi Arabia views suicide as a disgraceful and shameful
act more than any other Arab or Muslim country 32]. Similar results have been found in the United Arab Emirates, in which the annual
rate of suicide in Dubai between 1992 and 2000 was approximately 6.2/100,000 33], 34]. We found no significant difference in suicide incidence between Muslims and non-Muslims,
despite the fact that suicide is prohibited in Islam and is regarded as a sinful act
similar to homicide. It appears that the stresses and probable depression that suicide
victims feel prior to their demise supersede any religious teachings.