Suicidal Ideation Among Indian Expats in the Middle East During the COVID-19 Pandemic

Prim Care Companion CNS Disord 2021;23(6):21br02974

To cite: Uvais NA. Suicidal ideation among Indian expats in the Middle East during the COVID-19 pandemic. Prim Care Companion CNS Disord. 2021;23(6):21br02974.
To share: https://doi.org/10.4088/PCC.21br02974

© Copyright 2021 Physicians Postgraduate Press, Inc.

^aDepartment of Psychiatry, Iqraa International Hospital and Research Centre, Calicut, Kerala, India
*Corresponding author: N. A. Uvais, MBBS, DPM, Department of Psychiatry, Iqraa International Hospital and Research Centre, Calicut, Kerala, India (druvaisna@gmail.com).

The coronavirus disease 2019 (COVID-19) pandemic is presenting an unprecedented global challenge for mental health care services, and emerging evidence suggests adverse effects on a range of aspects of mental health, including suicidal ideation.¹ Lockdown, social distancing, domestic violence, economic adversity, unemployment, and disruptions to existing mental health services could increase the risk of suicide, especially among vulnerable populations.² A significant proportion of expat workers in the Middle East are low skilled, low paid, and without job security and are living in labor camps or overcrowded buildings, separated from their spouses and families for years.³ Studies have indicated that expat workers in the Middle East are at increased risk for stress and suicidal ideation. Dervic et al⁴ investigated suicide rates in the national and expat population in Dubai and found that the suicide rate among expats was 7 times higher than that of nationals, and approximately 3 of 4 expat suicides were committed by Indians. Al-Waheeb and Al-Kandary⁵ also explored patterns of suicide in Kuwait from 2003 to 2009 and found that regions that were more populated with an expat labor force had the highest suicide prevalence. The COVID-19 pandemic, as a negative life event, can significantly exacerbate suicidal thoughts among this vulnerable group. At the time of this writing, there are no studies exploring suicidal thoughts among the expat population during the COVID-19 pandemic. Considering the relevance of all the above factors, this study aimed to evaluate depression and suicidal thoughts among Indian expats working in the Middle East during the COVID-19 pandemic.

Methods

This was a cross-sectional, observational survey study. A snowball sampling technique was used to recruit participants. An online self-report questionnaire was designed using Google forms. Ethical committee approval was obtained for this study. In addition to demographic data, 2 COVID-19 pandemic–related questions were added (ie, Have you been exposed to COVID-19 patients? Have you been quarantined?). The 9-item Patient Health Questionnaire (PHQ-9)⁶ was also incorporated to assess the level of depression. For the PHQ‐9, scores of 5 to 9, 10 to 14, 15 to 19, and 20 to 27 corresponded to mild, moderate, moderately severe, and severe depression symptoms, respectively. Thoughts of suicide were assessed using the final item of the PHQ-9 (experiencing thoughts that you would be better off dead or of hurting yourself in some way).

The link to the questionnaire was sent through WhatsApp and other social media platforms to the contacts of the investigators, and the participants were encouraged to forward the survey to at least 10 more people. After receiving and clicking the link, the participants were automatically directed to information about the study, and after accepting to take part in the survey, they provided demographic details and answered questions related to the COVID-19 pandemic and the PHQ-9. The data collection was initiated on April 12, 2020 at 7 pm IST.

Data were analyzed using the Statistical Package for Social Sciences version 14 (SPSS Inc, Chicago, Illinois). Means, standard deviations (SDs), frequencies, and percentages were used to describe the data. Spearman correlation was used to study the association of demographic and COVID-19–related variables with depression and suicidal thoughts.

Results

Between April 12, 2020, and April 18, 2020, 251 responses were received. Of the sample, 70.5% were between the ages of 31 and 50 years, 91.2% were male, 88.8% were married, and 94.8% were Muslim. Also, 6.4% of the sample reported a history of exposure to COVID-19–positive individuals and 9.6% reported being quarantined. Clinically significant depression levels were reported by 33.2% of the respondents as follows: mild depression (21.1%), moderate depression (6.7%), moderately severe depression (4.5%), and severe depression (0.9%). Suicidal thoughts were reported by 8.8%, with a frequency of several days (6.7%), more than half the days (0.4%), and nearly every day (1.7%). There was a statistically significant negative correlation between suicidal thoughts and age (–0.133, P < .05). The levels of depression showed a statistically significant positive correlation with suicidal thoughts (0.301, P < .01). The details of the study are summarized in Table 1.

Discussion

This study evaluated depression and suicidal thoughts among Indian expats working in the Middle East. Results show that 33.2% of the study population suffered from clinically significant depression symptoms, and 8.8% had suicidal thoughts. The rate of depression in this study is significantly higher compared to past studies done among the expat population during the pre–COVID-19 period.⁷ Moreover, the rate of depression is higher when compared to studies conducted in the Indian population during the COVID-19 pandemic.⁸ However, the rate of suicidal thoughts in the present study is only slightly higher than past studies. Al-Maskari et al⁷ conducted a cross-sectional survey of depression and suicidal behavior among 239 male migrant workers in the United Arab Emirates and found that 25% of workers suffered from depression, 6.3% reported suicidal thoughts, and 2.5% had attempted suicide. The reason for the discrepancy between depression rate and suicidal thoughts could be that the majority of the respondents were Muslim. Shah and Chandia⁹ explored the correlation between suicide rates in the general population and the percentage of people in the general population adherent to Islam and found significant negative correlations between suicide rate and the percentage of people adherent to Islam while controlling for socioeconomic status and income inequality. Also, a recent Google trend study¹⁰ evaluating the association between the number of COVID-19 cases and deaths and public interest in mental health search terms including suicide among 24 countries also found that there were significant negative correlations between the relative search volume for the term suicide and the number of COVID-19 cases and deaths in Argentina, Australia, Brazil, Canada, the United Kingdom, and the United States. The authors¹⁰ maintained that during the proximity of life-threatening events, individuals become more resilient and use adaptive coping strategies.

In conclusion, this study found that 33.2% of the study population suffered from clinically significant depression and 8.8% had suicidal thoughts. These findings indicate that there is an urgent need to improve mental health support among the expat population in the Middle East.

Received: March 21, 2021.
Published online: October 28, 2021.
Potential conflicts of interest: None.
Funding/support: None.