Risk factors of suicidality among married adults: A cross-sectional survey in Rajshahi City, Bangladesh.

BACKGROUND: Suicide is a serious public health concern all over the world including Bangladesh. About 9% of the patients admitted with suicidal ideation (SI) or suicide attempt (SA) later complete suicide. To understand and prevent suicide, the study of SI and SA is necessary but research in this area is scanty in Bangladesh. Therefore, we studied suicidality (SI and SA) among married adults in Rajshahi City, Bangladesh.
METHODS: This was a household cross-sectional study. A total of 708 married adults were selected for this study using a multi-stage random sampling. Suicidality was measured based on two factors: (i) suicidal ideation, and (ii) suicide attempt. Frequency distribution, Chi-square test and multiple binary logistic regression model were used in this study according to our objectives.
RESULTS: The prevalence of suicidal ideation, suicide attempt, and suicidality was 5.8%, 3.4%, and 8.3% respectively among married adults. A multiple binary logistic regression model provided the following risk factors of suicidality: (i) joint family (AOR = 0.310, p<0.01), (ii) ≥26 years of age at the first marriage (AOR = 0.379, p<0.05), (iii) twice or more marriage (AOR = 0.214, p<0.01), (iv) conjugal life of ≥16 years (AOR = 0.410, p<0.05), (v) having no child (AOR = 6.343, p<0.01) and (vi) having 1-2 children (AOR = 6.190, p<0.01), (vii) medical comorbidity (AOR = 0.421, p<0.01), (viii) mental comorbidity (AOR = 0.253, p<0.01), (ix) stress-anxiety (AOR = 0.311, p<0.01), (x) family history of mental disorders (AOR = 0.059, p<0.01), (xi) family history of suicide/suicide attempt (AOR = 0.009, p<0.01), (xii) substance abuse (AOR = 0.065, p<0.01), (xiii) poor relationship with spouse (AOR = 0.209, p<0.01), and (xiv) poor relationship with other family members (AOR = 0.347, p<0.05).
CONCLUSION: The prevalence of suicidality is remarkable in Rajshahi city, Bangladesh. The government and non-government agencies can use the findings of this study to identify the vulnerable groups and undertake measures for preventing and reducing suicidality.

Introduction

Suicide is a serious public health concern all over the world. Global yearly deaths due to suicide estimate at about 800,000 people [1]. To understand and prevent suicide, the study of suicidal ideation (SI) and suicide attempt (SA) is necessary, as suicide is highly predicted by suicide attempt (SA) [2,3] and 8.6% of the patients admitted with suicidal ideation (SI) or SA would later complete suicide [4]. In the USA, 80% of attempters completed suicide within the next one year [5]. There are estimates of more than 20 SAs preceding one completed suicide [6]. SA was found to be the single most predictor of completed suicide in many other studies also [7-11]. The actual and complete picture of SAs cannot be known because most of the incidents are kept unreported or hidden by the families to avoid social and legal consequences and the cases coming to the healthcare service centers are only the tip of the iceberg [6,12-14]. On the other hand, SI is an important predictor of SA. SI was found to be highly correlated to SA in the future [15-17]. An Indian study found 24.6% and 7.1% of the adult population having SI and SA [18]. According to a population-based study in rural central India, the past 6-month prevalence of SI and SA was 5.1% and 4.2% respectively [19]. Among Pakistani medical students, 31.4% had SI [20]. A later study reported that 35.6% of Pakistani medical students had SI, 13.9% planned to commit suicide, and 4.8% attempted suicide [21]. In Sri Lanka, the risk of SA significantly varied between 21.0% in households and 4.0% in communities [22]. Another study found that 35.3% of the Nepalese population had high intent of committing suicide and 6.0% attempted suicide [23]. The life-time prevalence of SI was 20.0% among medical students in Nepal [24] and 3.1% among the general population in Bhutan [25].

A study conducted in the Indian subcontinent countries revealed that 10% of the number of suicides in the world was committed in India, Pakistan and Sri Lanka and suicides in other countries of the subcontinent (Bangladesh, Nepal, Afghanistan, Bhutan, and the Maldives) were not well-documented [26]. A review study demonstrated that in six South Asian countries (Afghanistan, Bangladesh, India, Nepal, Pakistan, Sri Lanka) the reported suicide rates ranged from 0.43 (Pakistan) to 331.0 (India) per 100,000 population, the non-pooled average rate of suicide being 25.2 (58.3 in Bangladesh) [27]. An epidemiological study found that the overall rate of suicide was 7.3 per 100,000 per year in Bangladesh [28].

A study estimated that 28.18% of people attempted suicide in the past year of the survey in Bangladesh [29]. On the other hand, 23.0% of elderly people in rural area of Bangladesh had suicidal ideation [30]. Another study observed that the prevalence of suicidal ideation was 5.0% among adolescents (14–19 years) in Bangladesh [31]. According to another study, 11.0–14.0% of ever-married women of reproductive age in Bangladesh reported suicidal ideation [32].

The main risk factors for suicide in the USA are summarized as: prior suicide attempt, mental disorders, substance abuse disorder, family history of a mental health, family history of substance abuse disorder, family history of suicide, family violence, having guns or other firearms in the home, being in prison or jail, being exposed to others’ suicidal behavior, medical illness, being between the ages of 15 and 24 years or over age 60, social isolation, criminal problems, financial problems, impulsive or aggressive tendencies, job problems or loss, relationship problems such as a break-up, violence, or loss, and sexual violence [33-36]. Though most of these factors are also common, the high use of organophosphate pesticides, larger numbers of married women, fewer elderly people, and problems of interpersonal relationship and adverse life events appear as additional important risk factors for suicide in the Indian subcontinent [26]. A review study found that emotional stress due to quarrel in family, poverty, long-term illness, failure in exam, suicidal death in near relative, substance abuse, stressful events, history of criminal behavior, social deprivation, uncertainty about future, not raised by biological parents and marital disharmony are the most common risk factors of suicide in Bangladesh [37].

However, to the best of our knowledge, the study on suicidality (SI and SA) among urban married adults in Bangladesh is not available. Usually, in Bangladesh, married adults are the key persons for earning livelihood and maintain their families. Suicidality among them disrupts the whole family. The situation is worse in urban area because married adults depend mainly on business and services for their livelihood. Due to their importance in family, it is necessary to investigate the suicidality among them.

Therefore, the objectives of this study were: (i) to determine the prevalence of suicidal ideation, suicide attempt and the overall suicidality, and (ii) to investigate the associated factors of suicidality among married adults in Rajshahi City, Bangladesh.

Materials and methods

Study design, setting, and population

This was a household-based cross-sectional study and Rajshahi City area was our study area. Rajshahi City is one of the four biggest cities in Bangladesh and the headquarters of Rajshahi Division, the north-western region of the country. The city consists of 97.17 square kilometers area and is divided into 30 Wards (administrative units). It comprises 99,222 households [29]. Married adults living in this city were considered as our study population. Only legally married adults aged at least 18 years were included in the study. The survey was conducted from May 15 to July 30, 2019. The present study was a part of our project.

Sample size determination and sampling

For determining the sample size, the mathematical formula n = N/ (1+Nd2) was used in this study, where n = sample size, N = population size, and d (margin of error) = 0.05. The formula showed that 398 households would suffice for this study. We assumed a 90% rate of response and decided to select 450 households. For sample selection, a multistage random sampling technique was applied. Before sampling, we went to the Rajshahi City Corporation Office and collected the necessary information about Wards, muhallahs, and households. Then, at first, we selected three Wards by a simple random sampling (lottery), in the second stage, three muhallas from each selected Ward by lottery, and lastly, 50 households from each selected muhalla again by lottery. One married male and one married female were selected from each selected household. We selected them by lottery when there were more than one married male and one married female in a household.

Ethical approval

The ethical approval for our study was given by the Institutional Animal, Medical Ethics, Biosafety and Biosecurity Committee (IAMEBBC) for Experimentation on Animal, Human, Microbes and Living Natural Sources, Institute of Biological Sciences, University of Rajshahi, Bangladesh (Memo No: 120/ 320/ IAMEBBC/ IBSc, dated April 11, 2019).

Data collection

A self-developed semi-structured questionnaire was used for data collection in this study. The questionnaire included demographic, socioeconomic, and comorbidity-related questions and statements. The original questionnaire was drafted in English and then translated to Bangla, the mother language of Bangladesh to make it easily comprehensible. The first author prepared the first drafts of both English and Bangla versions of the questionnaire and the other authors reviewed, edited, and improved it. A total of six interviewers were trained and employed for data collection. Under the direct supervision of the first and last authors, the interviewers went to the selected households and briefed the selected married adults about the study aims and procedures. We had a target of collecting information from 900 respondents from the selected 450 households. But 73 married adults disagreed to give interviews, and 66 others were not available in their households at the time of the survey. Thus, a total of 139 (73+66 = 139) respondents were excluded from the study. Written informed consent was taken from the rest 761 (900–139 = 761) agreed respondents and they were interviewed face-to-face. While entering data into the computer, 53 questionnaires were discarded for missing information. Finally, we had data of 708 respondents for analysis.

Variables

In the current study, suicidality was the principal outcome variable and it was measured based on two factors: (i) suicidal ideation, and (ii) suicide attempt. Suicidal ideation was assessed by the response of the respondents to a question ‘Did you ever think of committing suicide in the last six months?’ and suicide attempts by the response to a question ‘Did you ever attempt to commit suicide in the last six months?’ Each of these two questions was assigned two options of the answer‒ ‘no’ (score 0) and ‘yes’ (score 1). Suicidality was measured by addition of suicidal ideation and suicide attempt, the sum of score would be 0, or 1, or 2 of a respondent. We classified our sample into two groups; (i) no suicidality (sum of score 0; code 0), and (ii) suicidality (sum of score 1–2; code 1). We also considered suicide attempt as an outcome variable and suicidal ideation as an independent variable to examine the association between these two factors and assess the impact of suicidal ideation on suicide attempt among married adults. For identifying risk factors of suicidality, we considered some well-used household, demographic, socioeconomic, familial, and comorbidity-related factors as independent variables in this study (Table 1).

Table 1

Selected independent variables with their categories, definition, codes and frequency distribution.

Variable	Category	N (%)
Age (in year)	18–25	188 (26.55)
	26–35	281 (39.69)
	≥36	239 (33.76)
Gender	Male (husband)	354 (50.0)
	Female (wife)	354 (50.0)
Education level	Uneducated	75 (10.59)
	Primary	216 (30.51)
	Secondary	204 (28.81)
	Higher	213 (30.09)
Respondent’s occupation	Homemaker (housewife)	316, (44.63)
	Hard-worker (labor and farmer)	211 (29.81)
	Service	181 (25.56)
Respondent’s nutritional status	Under-nourished (BMI<18.5 kg/m2)	40 (5.65)
	Healthy (18≤BMI<25 kg/m2)	443 (62.57)
	Over-nourished (BMI≥25 kg/m2)	225 (31.78)
Monthly family income	Poor (≤20,000 Taka)	225 (31.78)
	Middle (20,001–40,000 Taka)	419 (59.18)
	Rich (≥40,001 Taka)	30 (4.24)
Type of family	Nuclear (family of parents and children)	524 (74.01)
	Joint (family of parents, children, grandparents, grandchildren and relatives)	194 (27.40)
Number of ever-born children	No child	86 (12.15)
	1–2 children	443 (62.57)
	≥3 children	179 (25.28)
Duration of present conjugal life (year)	≤5	214 (30.23)
	6–15	306 (43.22)
	≥16	188 (26.55)
Number of marriage	One	687 (97.03)
	2 or more	21 (2.97)
Age at the first marriage (year)	<18	198 (27.97)
	18–25	435 (61.44)
	≥26	75 (10.59)
Death of children	No	628 (88.70)
	Yes	80 (11.30)
Stress-anxiety	No	520 (73.45)
	Yes	188 (26.55)
Your relationship with the spouse	Poor	23 (3.25)
	Good	685 (96.75)
Your relationship with other family members	Poor	34 (4.80)
	Good	674 (95.20)
Medical comorbidity	No	614 (86.72)
	Yes	94 (13.28)
Mental comorbidity	No	677 (95.62)
	Yes	31 (4.38)
Family history of mental disorders	No	684 (95.62)
	Yes	24 (4.38)
Substance abuse	No	662 (93.50)
	Yes	46 (6.50)
Family history of suicide/suicidal attempt	No	667 (94.21)
	Yes	41 (5.79)

Statistical analysis

The data were presented as mean and standard deviation (SD) for the numerical variables and frequency with percentage (%) for the categorical variables. We applied descriptive analysis for determining the prevalence of suicidal ideation, suicide attempt, suicidality, and the sample characteristics, the chi-square test for examining the associated factors of suicidality, and multivariable binary logistic regression model for identifying the most contributory risk factors of suicidality and impact of suicidal ideation on suicide attempt. For data analysis, SPSS (IBM, version 22) was used. Statistical significance was accepted at p<0.05 and a 95% confidence interval (CI) were set for the odds ratio.

Results

A total number of 708 married adults living in Rajshahi city, Bangladesh were considered as sample to investigate suicidality in last six-month of our survey. The mean age of our subject was 33.21±10.39 years with age range from 18 to 82 years. 10.6% and 30.1% married adults were uneducated and higher educated respectively. The prevalence of medical and mental comorbidities among adults was 32.1% and 4.4% respectively. It was observed that 44.6%, 29.8% and 25.6% married adults were homemakers, hard workers and service holders respectively (Table 1). The mean duration of their conjugal life was 11.23±8.81 years with range from 1 to 45 years.

Prevalence of suicidal ideation, suicide attempt, and suicidality

The prevalence rate of suicidality was found to be 8.3%, 9.0%, and 7.6% among married adults, males, and females respectively (Fig 1). The same figure shows that the prevalence of suicidal ideation was 5.8%, 5.4%, and 6.2%, and of suicide attempt was 3.4%, 4.5%, and 2.3% among married adults, males, and females respectively (Fig 1).

Fig 1

Prevalence of suicidal ideation, suicidal attempt, and suicidality among married adults in Rajshahi City, Bangladesh.

Association of suicidality

The chi-square test revealed that type of family, number of ever-born children, age at the first marriage, number of marriage, duration of conjugal life, death of children, medical comorbidity, mental comorbidity, family history of mental disorders, stress-anxiety, family history of suicide/attempt, substance abuse, relation with the spouse, and relation with other family members were significantly (p<0.05) associated with suicidality among married adults in Rajshahi City, Bangladesh (Table 2).

Table 2

Association between selected independent variables and suicidality among married adults (n = 708).

Variables, Category	Suicidality N (%)	No Suicidality N (%)	χ2-value	p-value
Gender			0.462	0.587
Male	32 (9.0)	322 (91.6)
Female	27 (7.6)	327 (92.4)
Age (Year)			0.749	0.701
18–25	13 (6.9)	175 (93.1)
26–35	24 (8.5)	257 (91.5)
≥36	22 (9.2)	217 (90.8)
Education level			5.400	0.144
Uneducated	9 (12.0)	66 (88.0)
Primary	11 (5.1)	205 (94.9)
Secondary	17 (8.3)	187 (91.7)
Higher	22 (10.3)	191 (89.7)
Respondent’s occupation			0.521	0.777
Homemaker	25 (7.9)	291 (92.1)
Hard worker	20 (9.5)	191 (90.5)
Service	14 (7.7)	167 (92.3)
Monthly family income (Taka)			2.735	0.284
Poor, ≤20,000	48 (9.3)	466 (90.7)
Middle, 20,001–40,000	10 (6.1)	154 (93.9)
Rich, ≥40,001	1 (3.3)	29 (96.7)
Respondent’s nutritional status			2.354	0.321
Under-nourished	3 (7.5)	37 (92.5)
Healthy	32 (7.2)	411 (92.8)
Over-nourished	24 (10.7)	207 (89.3)
Type of family			17.787	0.001
Nuclear	29 (5.6)	485 (94.4)
Joint	30 (15.5)	165 (84.5)
Number of ever-born children			11.512	0.003
No child	12 (14.0)	74 (86.0)
1–2 children	42 (9.5)	401 (90.5)
≥3 children	5 (2.8)	174 (97.2)
Age at the first marriage (Year)			7.885	0.019
<18	9 (4.5)	189 (95.5)
18–25	39 (9.0)	396 (91.0)
≥26	11 (14.7)	64 (85.3)
Number of marriage			6.786	0.024
One	54 (7.9)	633 (92.1)
2 or more	5 (23.8)	16 (76.2)
Duration of present conjugal life (year)			9.981	0.007
≤5	27 (12.6)	187 (87.4)
6–15	15 (4.9)	291 (95.1)
≥16	17 (9.0)	171 (91.0)
Death of child			5.247	0.025
No	47 (7.5)	581 (92.5)
Yes	12 (15.0)	68 (85.0)
Medical comorbidity			16.598	0.001
No	41 (6.7)	573 (93.3)
Yes	18 (19.1)	76 (80.9)
Mental comorbidity			27.408	0.001
No	25 (4.9)	483 (95.1)
Yes	34 (17.0)	166 (83.0)
Family history of mental disorders
No	47 (6.9)	637 (93.1)	56.459	0.001
Yes	12 (50.0)	12 (50.0)
Stress-Anxiety			19.478	0.001
No	29 (5.6)	491 (94.4)
Yes	30 (16.0)	158 (84.0)
Family history of suicide/attempt			289.938	0.001
No	22 (3.4)	634 (96.6)
Yes	37 (71.2)	15 (28.8)
Substance abuse			100.447	0.001
No	37 (5.6)	625 (94.4)
Yes	22 (47.8)	24 (52.2)
Relationship with spouse			29.516	0.001
Good	50 (7.3)	635 (92.7)
Poor	9 (39.1)	14 (60.9)
Relationship with other family members			10.773	0.001
Good	49 (7.3)	625 (92.7)
Poor	10 (29.4)	24 (70.6)

Effect of associated factors on suicidality

The statistically significant associated factors (14 in number) found in the chi-square test (p-value<0.05) were put as independent variables in the multivariable binary logistic regression analysis. Being member of the joint family (p<0.01), ≥26 years of age at the first marriage (p<0.05), twice or more marriage (p<0.01), conjugal life of ≥16 years (p<0.05), having no child (p<0.01) and 1–2 children (p<0.01), medical comorbidity (p<0.01), mental comorbidity (p<0.01), stress-anxiety (p<0.01), family history of mental disorders (p<0.01), family history of suicide/attempt (p<0.01), substance abuse (p<0.01), poor relationship with spouse (p<0.01), and poor relationship with other family members (p<0.05) were found to show high odds of likelihood of developing suicidality among married adults (Table 3).

Table 3

Effect of the associated factors on suicidality among married adults (n = 708) in Rajshahi City, Bangladesh.

Variables	B	S. E	p-value	AOR	95% CI for AOR
					Lower	Upper
Type of family
Nuclear versus JointR	-1.172	0.305	0.001	0.310	0.170	0.563
Age at the first marriage
<18 years versus ≥26 yearsR	-0.970	0.493	0.049	0.379	0.144	0.998
18–25 years ≥26 yearsR	-0.199	0.388	0.608	0.820	0.383	1.754
Number of marriage
One versus ≥2R	-1.540	0.591	0.009	0.214	0.067	0.682
Duration of conjugal life
≤5 years ≥16 yearsR	-0.204	0.408	0.617	0.816	0.367	1.814
6–15 years ≥16 yearsR	-0.890	0.399	0.026	0.410	0.188	0.898
Death of child
No versus YesR	-0.481	0.383	0.209	0.618	0.292	1.308
Number of ever-born children
No child versus ≤3 ChildrenR	1.847	0.649	0.004	6.343	1.777	22.643
1–2 children versus ≤3 ChildrenR	1.823	0.538	0.001	6.190	2.156	17.772
Medical comorbidity
No versus YesR	-0.864	0.274	0.002	0.421	0.246	0.721
Mental comorbidity
No versus YesR	-1.376	0.278	0.001	0.253	0.146	0.436
Stress-Anxiety
No versus YesR	-1.168	0.276	0.001	0.311	0.181	0.534
Family history of mental disorder
No versus YesR	-2.835	0.594	0.001	0.059	0.018	0.188
Family history of suicide/attempt
No versus YesR	-4.766	0.462	0.001	0.009	0.003	0.021
Substance abuse
No versus YesR	-2.740	0.340	0.001	0.065	0.033	0.126
Relationship with spouse
Good versus PoorR	-1.567	0.528	0.003	0.209	0.074	0.587
Relationship with family members
Good versus PoorR	-1.059	0.486	0.029	0.347	0.134	0.899

N. B.: B-Coefficient; S. E. -Standard Error; AOR -Adjusted Odds Ratio; CI -Confidence Interval;

R -Reference.

Impact of suicidal ideation on suicide attempt

After controlling the effect of other selected factors, multiple logistic regression model showed that married adults having suicidal ideation had 83.8% of higher chance to attempt suicide than their counterparts (AOR = 0.162, 95% CI = 0.060–0.433, p<0.01) (Table 4).

Table 4

Impact of suicidal ideation on suicide attempt among married adults in Rajshahi City, Bangladesh.

Variables	B	S. E	p-value	AOR	95% CI for AOR
					Lower	Upper
Suicidal Ideation
No versus YesR	-1.821	0.502	0.001	0.162	0.060	0.433

N. B.: B-Coefficient; S. E. -Standard Error; AOR -Adjusted Odds Ratio; CI -Confidence Interval;

R -Reference.

Discussion

In this study, we determined the six-month prevalence of suicidal ideation, suicide attempt, and overall suicidality (both SI and SA), identified the risk factors of suicidality, and the effect of suicidal ideation on suicide attempt among married adults living in Rajshahi City, Bangladesh.

The findings of this study regarding the six-month prevalence of SI and SA among married adults were remarkably less than that found in a few previous studies with other types of populations in Bangladesh [29-31]. However, in the context of other countries, the findings of this study were acceptable. In the USA, incidents of SA were 0.79% in 2013 [38]. Another USA study reported 3.8% of adults had SI in the last one year [16]. The 12-month prevalence of SI was 3.4% in Australia [17]. An Indian study found 24.6% of SI and 7.1% of SA among the adult population [18]. According to another Indian study, the past 6-month prevalence of SI and SA was 5.1% and 4.2% respectively [19]. The prevalence of SI and SA was much higher among Pakistani medical students [20-21] and in Sri Lanka, the risk of SA significantly varied between 21.0% in households and 4.0% in communities [22]. Nepalese studies found that the rate of SI was higher in that country, 35.3% among the general population [23], and 20.0% among medical students [24]. However, in Bhutan, SI was found in 3.1% of the general population [25].

In a rural area in Bangladesh, 28.18% of people attempted suicide in the past year [29]. In another study among elderly people in rural Bangladesh, suicidal ideation was found to be 23.0% [30]. Another study observed that the prevalence of suicidal ideation was 5.0% among adolescents of 14–19 years in Bangladesh [31]. Compared to these Bangladeshi findings, the prevalence of SI and SA in our study was remarkably less. The urban setting, the prevalence of last six months, and married status of the respondents in our study might be the reason for such a big difference. In a Muslim majority country like Bangladesh, suicide attempt and suicide are considered sin, and the person, and even the family as a whole, is socially stigmatized. Suicide and suicide attempt are also a crime in this country. That is why people try to keep most of the incidents unreported or hidden for avoiding social stigma and legal consequences [6, 12–14]. That might be a reason for the lower rate of SI and SA in our study. The prevalence of suicidality as a whole cannot be compared as it was not studied yet in Bangladesh, so far our knowledge goes.

Risk factors of suicidality

In this study, we found that joint family, ≥26 years of age at the first marriage, twice or more marriage, conjugal life of ≥16 years, having no child and ≥3 children, medical comorbidity, mental comorbidity, stress-anxiety, family history of mental disorders, family history of suicide/attempt, substance abuse, poor relationship with the spouse, and poor relationship with other family members contributed more to develop suicidality among married adults in Bangladesh. These factors fall into different categories such as individual, social, community, interpersonal relationships within the family, and also the healthcare system, and overlap one another [39]. Mentionable that risk factors differ in their importance in different countries and regions, and even within a country or region, differences are found in the prevalence of risk factors [40]. Some factors such as the increasing use of the internet and migration of people from one place to another place in the same country or region also influence the prevalence of risk factors [41]. Some risks were universal but some other risk factors in low-income countries differ from high-income countries [42-43]. In African countries, a study reported, difficult interpersonal relationships, physical and mental comorbidities, socioeconomic problems, and substance abuse were the common risk factors of suicide and SA [44] while in Latin America and the Caribbean, major depression, family dysfunction, and previous SA were found to be the common risk factors of SA [45]. Another study included younger and older age, mental comorbidity, low socioeconomic status, substance abuse, and prior SA as the universal risk factors of suicide [40]. Stress was also a risk factor common in both low- and high-income countries [43]. Depressive disorder, mental comorbidities, substance abuse or dependence were potential risk factors of suicide in low-income countries [46]. A Nigerian study reported that physical comorbidity was correlated to suicide [47]. History of suicide in the family is highly associated with suicidality [48,49]. An Indian study reported that difficult relationship with spouse and family members, substance abuse, and mental comorbidity significantly contributed to committing suicide [50]. Family conflicts and mental comorbidities were found to contribute more to suicide attempts in a study [51]. A recently published study observed that physical and mental comorbidities were important predictors of suicide attempts [52]. 12-month suicidal ideation and suicide attempts were associated with mental disorders like anxiety and depression and substance abuse [53]. Findings of all the above-mentioned studies reveal that physical and mental comorbidities, substance abuse, stress-anxiety, family history of suicide/attempt, and family conflicts are the universal predictors of suicidality that corroborates our findings. However, there are contradictions regarding other findings. Joint family, ≥26 years of age at the first marriage, twice or more marriage, conjugal life of ≥16 years, and having no child overlap one another and ultimately create family dysfunction contributing to suicidality.

In addition to some common universal factors like mental disorders, substance abuse disorder, family history of mental disorders, family history of suicide, chronic medical illness and problems of family relationship [33-36], this study added some other risk factors such as being member of a joint family, being ≥26 years of age at the first marriage, having twice or more marriage, having conjugal life of ≥16 years, having no child and ≥3 children. Unemployment, living in urban area, low level of education, being married, low socioeconomic status are also found to contribute to causation of suicidality in the Indian subcontinent countries [54-56].

Bangladesh is one of those countries where the surveillance system for suicide attempts is limited [6]. An estimated number of 20 suicide attempts result in one completed suicide [6] and as we have found in our study and many other studies, suicidal ideation is highly correlated to suicide attempt. These findings indicate that long-term surveillance and monitoring of suicidality and its risk factors can provide necessary information for the development of strategies for the prevention of suicidal deaths [6]. The combination of information on suicidality and suicidal deaths can help estimate case fatality rates that would ultimately assist in identifying high-vulnerable individuals [6,9]. Another important aspect is that there is a lack of internationally standardized protocol for data collection regarding suicide attempts that create methodological differences in the collection of data and surveillance [57]. A uniform approach is required for surveillance of both reported and unreported events of suicidality, and legal status and procedures of suicide and suicide attempt should also be considered [57].

Effect of suicidal ideation on suicide attempt

This study substantiated the fact that suicidal ideation was highly correlated to suicide attempt showing higher odds of likelihood of committing SA in the future as was revealed in many other previous studies in different populations [15,16].

Strength and limitations

Perhaps, this was the first time we attempted to study on suicidality among urban married adults in Bangladesh. Appropriate statistical models were used in this study that revealed some important findings. However, there are limitations too. The data was not nationally representative. Some variables like spousal violence methods of suicide attempts and self-perceived reason for SI and SA were not considered in this study. Since the data were self-reported, some events of SI and SA might be kept hidden that could produce underestimated results. The percentage of suicidality was very low, our selected logistic regression model was under-powered, we need more sample for getting achieve adequate power. Moreover, substance abuse was entirely self-reported and no validated scales were used, and the type of substance abused was unknown. More research is required on suicidality and suicide attempts among adults in Bangladesh.

Conclusions

This study aimed to identify the risk factors of suicidality among married adults in Rajshahi City, Bangladesh. A total of 708 samples were recruited for this study. The prevalence of suicidal ideation, suicide attempt, and suicidality was 5.8%, 3.4%, and 8.3% respectively. Joint family, ≥26 years of age at the first marriage, twice or more marriage, conjugal life of ≥16 years, having no child and ≥3 children, medical comorbidity, mental comorbidity, stress-anxiety, family history of mental disorders, family history of suicide/attempt, substance abuse, poor relationship with the spouse, and poor relationship with other family members were the most influential predictors of suicidality. Moreover, it was observed that suicidal ideation was the most important risk factor for suicidal attempt. The concerned government and non-government agencies can use the findings of this study to identify the vulnerable groups and individuals and undertake measures for preventing and reducing suicidality and suicide in the country.

(SAV)

Click here for additional data file.

22 Jan 2021

PONE-D-20-35857

Risk factors of suicidality among married adults: A cross-sectional survey in Rajshahi City, Bangladesh

PLOS ONE

Dear Dr. Hossain,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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PLOS ONE

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Reviewers' comments:

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Reviewer #1: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

**********

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Reviewer #1: No

**********

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Reviewer #1: Dear authors,

I consider the research topic important as suicide is a major public health concern in Bangladesh. I appreciate your work and I encourage you to address my comments and recommendations that could potentially increase the impact of your findings.

Major comments:

Introduction

• I recommend that the authors include more details about suicidality in Bangladesh i.e., sociocultural context, incidence, prevalence. In my opinion, the authors focused too much on US studies and relevant sociocultural differences exist between the US and Bangladesh. It would be useful for readers if the authors provided a synthesis of the main differences in suicidality between western countries and the Indian subcontinent.

• In my opinion, the introduction should contain a synthesis of the main factors that are known to influence suicidality with an emphasis on relevant factors in the Indian subcontinent.

• The authors provided the general aim of the study, but I recommend that they clearly state the objectives.

Methods

• I encourage the authors to provide more details related to the sample size calculation and how this translates into results interpretation. Since analyses included participants (two per household), how does the expected margin of error assist the reader in interpreting results i.e., suicidality, suicidal ideation and attempts? Why did the authors not calculate the sample size using the total population of Rajshahi? It is not clear from their sample calculation if the logistic models are adequately powered.

• I am unsure what was the rationale behind calculating a sum score for suicidality. The possible values for suicidality are 0, 1 or 2. Since you used binary logistic regression, please clarify what were the values of suicidality used in the calculation. I did not understand following statement because it is unclear how you calculated the percentile: “A percentile of ≥75% was considered as suicidality and <75% as no suicidality” (lines137-138).

• In my opinion, it would be important to describe how you measured substance abuse i.e., use of validated scales. Did the authors measure substance use or substance abuse?

• For exploring the correlates of suicide attempt, the authors could use a stepwise modelling approach (and enter in the step 1 sociodemographic variables and in step 2 suicidal ideation) and provide the variation attributable to suicidal ideation. As a suggestion, the authors could use “No” as reference category for suicidal ideation.

Results

Based on the percentage of suicidality of 8.3% your logistic regression model is under-powered as you need about 1600 observations to achieve adequate power. Peduzzi et al. recommended following formula to calculate the minimum sample for a binary logistic regression model n=10k/p where n=sample size; k=number of independent variables (14 in your model) and p the smallest proportion in the binary model (in this case 0.083). Therefore, more work is needed to find the most relevant variables for the final model e.g., based on societal characteristics), both for the analysis of suicidality and suicide attempts.

Discussion

• I recommend that the authors elaborate more on the differences in suicidality, suicide intentions and attempts found in their study compared to other studies conducted in western countries and the Indian subcontinent. In my opinion more work is needed to synthesize differences in relevant risk factors for suicidality compared to other studies.

Strengths and limitations,

• The authors may consider including in the limitations the fact that the study included a relatively small sample of participants, considering the low prevalence of suicidality/suicide attempts. Another limitation worth mentioning is that the authors did not include relevant risk factors of suicidality such as spousal violence, see Naved RT, Akhtar M “Spousal Violence Against Women and Suicidal Ideation in Bangladesh”, Women’s Health Issues 18 (2008) 442–452

Minor comments:

• Some statements lack clarity and need revising e.g., Introduction, lines 63-64 “A study found that SA recorded 0.79% of the lifetime prevalence and 0.29% of the past 12-month prevalence”

• Methods: For clarity, please revise the description of the number of questionnaires analysed. The authors mention on line 126: “Thus, a total of 139 samples were excluded from the study” and I am unsure if samples mean households or participants. If the authors excluded 139 households then data was collected from 311 households (i.e., 450-139=311) and 622 participants (311*2 as 2 adults per household were interviewed). Therefore, I am unsure why the authors mentioned that 761 individuals participated.

• Methods: Please provide the rationale for asking about suicidal ideation and attempts in the last 6 months instead of the last 12 months (frequently used in this field)

• Methods, Table 1-in my opinion this should be merged with results and contain percentages for each category (variable); providing the coding is less informative. I suggest that the authors provide explanations whether they measured gender identity or biological sex. For improving clarity, following variables should be better explained: “homemaker”; “hard-worker” (also called headworker, line160), “nuclear” and “joint” family. Please clarify if the variable “Respondent’s suicidal thought/attempt” is equivalent with suicidality.

• Results: I suggest that the authors describe the substances of use/abuse (including the main substance used if the information is available) and the medical and mental comorbidities.

• Results provided in table 2 and Table 3 could be merged to give the reader a better overview of the relevance of the variables in bivariate and multivariate analyses.

• Results, lines 179-193, since most results are provided in Table 3, the paragraph could be shortened

• Please provide the number of observations included in the binary logistic regression models

Relevant articles related to suicide in Bangladesh:

Jordans et al. BMC Psychiatry (2014) 14:358. “Suicide in South Asia: a scoping review” DOI 10.1186/s12888-014-0358-9

Saidur Rahman Mashreky , Fazlur Rahman & Aminur Rahman (2013) Suicide

Kills More Than 10,000 People Every Year in Bangladesh, Archives of Suicide Research, 17:4,

387-396, DOI: 10.1080/13811118.2013.801809

Murad M. Khan. Suicide on the Indian Subcontinent. Crisis 2002; Volume 23 (3): 104–107. DOI: 10.1027//0227-5910.23.3.104

**********

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14 Mar 2021

Response to Reviewers

Journal Name: PLOS ONE

Tracking No. ( Manuscript ID): PONE-D-20-35857

Manuscript Title: “Risk factors of suicidality among married adults: A cross-sectional survey in Rajshahi City, Bangladesh"

Dear Editor

Thank you very much for providing reviewer’s comments on our manuscript. We have modified and revised the manuscript accordingly, and detailed corrections point–by-point is given below:

Review Comments to the Author:

Reviewer #1:

I consider the research topic important as suicide is a major public health concern in Bangladesh. I appreciate your work and I encourage you to address my comments and recommendations that could potentially increase the impact of your findings.

Authors’ Response: Thank you for your kind efforts for improving our manuscript. We appreciate your comments and suggestions on the manuscript.

Major comments:

Introduction

• I recommend that the authors include more details about suicidality in Bangladesh i.e., sociocultural context, incidence, prevalence. In my opinion, the authors focused too much on US studies and relevant sociocultural differences exist between the US and Bangladesh. It would be useful for readers if the authors provided a synthesis of the main differences in suicidality between western countries and the Indian subcontinent. In my opinion, the introduction should contain a synthesis of the main factors that are known to influence suicidality with an emphasis on relevant factors in the Indian subcontinent.

Authors’ Response: According to your suggestions, we added some new information and facts about suicide in Indian subcontinent with Bangladesh [Page 5, Line 82-90; Page 6, Line 97-111].

• The authors provided the general aim of the study, but I recommend that they clearly state the objectives.

Authors’ Response: According to your recommendation, we added specific objectives [Page 7, Line 119-122.

Methods

• I encourage the authors to provide more details related to the sample size calculation and how this translates into results interpretation. Since analyses included participants (two per household), how does the expected margin of error assist the reader in interpreting results i.e., suicidality, suicidal ideation and attempts? Why did the authors not calculate the sample size using the total population of Rajshahi? It is not clear from their sample calculation if the logistic models are adequately powered.

Authors’ Response: You know, this was a household study, and we considered married couple who were living together in Rajshahi city as a study population. We got the information about total number of households in Rajshahi city from Rajshahi city corporation office. Since we had the total number of households, we used the mentionable formula to calculate the required number of households (sample, married couple living in household). We have described in details about the sample size determination in Page, 7; Line: 132-135.

We think no need to mention statistical model which would be used for analyzing data like Logistic regression in subtitle “Sample size determination and Sampling” if we consider a formula for calculating sample size which is not related to a specific statistical model.

• I am unsure what was the rationale behind calculating a sum score for suicidality. The possible values for suicidality are 0, 1 or 2. Since you used binary logistic regression, please clarify what were the values of suicidality used in the calculation. I did not understand following statement because it is unclear how you calculated the percentile: “A percentile of ≥75% was considered as suicidality and <75% as no suicidality” (lines137-138).

Authors’ Response: We measured suicidality by addition of suicidal Ideation and Suicide Attempt. That is why we calculated the sum score. You correctly assumed that values for suicidality are 0, 1 or 2. We could assume 0 for No Suicidality and 1-2 for Suicidality for using binary logistic regression. But we followed a new idea of making a cut-off point at 75% of sum score of Suicidality and a percentile of ≥75% of the sum score was considered as suicidality and <75% of the sum score as no suicidality”.

• In my opinion, it would be important to describe how you measured substance abuse i.e., use of validated scales. Did the authors measure substance use or substance abuse?

Authors’ Response: We measured substance abuse by a question ‘Are/were you addicted?’ with two options of answer ‘yes’ and ‘no’. We did not use any scale for measuring substance abuse.

• For exploring the correlates of suicide attempt, the authors could use a stepwise modelling approach (and enter in the step 1 sociodemographic variables and in step 2 suicidal ideation) and provide the variation attributable to suicidal ideation. As a suggestion, the authors could use “No” as reference category for suicidal ideation.

Authors’ Response: Thank you for your suggestion. We considered “yes” as reference case for keeping similarity of binary logistic and stepwise logistic results.

Results

Based on the percentage of suicidality of 8.3% your logistic regression model is under-powered as you need about 1600 observations to achieve adequate power. Peduzzi et al. recommended following formula to calculate the minimum sample for a binary logistic regression model n=10k/p where n=sample size; k=number of independent variables (14 in your model) and p the smallest proportion in the binary model (in this case 0.083). Therefore, more work is needed to find the most relevant variables for the final model e.g., based on societal characteristics), both for the analysis of suicidality and suicide attempts.

Authors’ Response: We followed a publication where authors used the formula that we used in our present study for calculating sample size, and binary logistic regression was used in that paper [Please see, “Assessment of knowledge regarding tuberculosis among non-medical university students in Bangladesh: a cross-sectional study”] but we agree with you. Yes, more work is needed regarding this issue, we have mentioned in Limitation [Page, 20-21; Line: 333-336].

Discussion

• I recommend that the authors elaborate more on the differences in suicidality, suicide intentions and attempts found in their study compared to other studies conducted in western countries and the Indian subcontinent. In my opinion more work is needed to synthesize differences in relevant risk factors for suicidality compared to other studies.

Authors’ Response: We have tried to follow your suggestion and revised some parts of Discussion [Page 19, Line 303-309].

Strengths and limitations

• The authors may consider including in the limitations the fact that the study included a relatively small sample of participants, considering the low prevalence of suicidality/suicide attempts. Another limitation worth mentioning is that the authors did not include relevant risk factors of suicidality such as spousal violence, see Naved RT, Akhtar M “Spousal Violence Against Women and Suicidal Ideation in Bangladesh”, Women’s Health Issues 18 (2008) 442–452

Authors’ Response: We have added the suggested limitations [Page 20, Line 331-332].

Minor comments:

• Some statements lack clarity and need revising e.g., Introduction, lines 63-64 “A study found that SA recorded 0.79% of the lifetime prevalence and 0.29% of the past 12-month prevalence”

Authors’ Response: This sentence was revised [Page 4, Line 63-65].

• Methods: For clarity, please revise the description of the number of questionnaires analyzed. The authors mention on line 126: “Thus, a total of 139 samples were excluded from the study” and I am unsure if samples mean households or participants. If the authors excluded 139 households then data was collected from 311 households (i.e., 450-139=311) and 622 participants (311*2 as 2 adults per household were interviewed). Therefore, I am unsure why the authors mentioned that 761 individuals participated.

Authors’ Response: We selected 450 households and targeted to collect information from two married people (one male and one female) from one household, i.e., the number of respondents would be 900. But 73 disagreed to give interviews, and 66 were not available in their households at the time of the survey, thus, a total of 139 (73+66=139) respondents could not be interviewed. The rest 761 (900-139=761) respondents were interviewed. For the sake of clarity we revised this portion [Page 8, Line 156-160].

• Methods: Please provide the rationale for asking about suicidal ideation and attempts in the last 6 months instead of the last 12 months (frequently used in this field)

Authors’ Response: Actually this study is a part of a project entitled “Household study on dual burden of bipolar disorders among couples of Rajshahi city in Bangladesh”. For that project time of reference for all information was last 6 months. That is why we could not avoid 6 months instead of 12 months.

• Methods, Table 1-in my opinion this should be merged with results and contain percentages for each category (variable); providing the coding is less informative. I suggest that the authors provide explanations whether they measured gender identity or biological sex. For improving clarity, following variables should be better explained: “homemaker”; “hard-worker” (also called headworker, line160), “nuclear” and “joint” family. Please clarify if the variable “Respondent’s suicidal thought/attempt” is equivalent with suicidality.

Authors’ Response: Table 1 has been revised according to your suggestion. Actually, we did not use the variable Respondent’s suicidal thought/attempt”, so we have deleted from the Table.

• Results: I suggest that the authors describe the substances of use/abuse (including the main substance used if the information is available) and the medical and mental comorbidities.

Authors’ Response: These specific information were not available. So we could not mention or describe these.

• Results provided in table 2 and Table 3 could be merged to give the reader a better overview of the relevance of the variables in bivariate and multivariate analyses.

Authors’ Response: Thank you for your suggestion. You know, we put Chi-square test and logistic regression results in Table 2 and Table 3 respectively. In this study, Chi-square test was used to select the independent variables for logistic model. We think no need to merge Table 2 and Table 3.

• Results, lines 179-193, since most results are provided in Table 3, the paragraph could be shortened.

Authors’ Response: We have shortened the said paragraph [Page 14; Line: 214-225].

• Please provide the number of observations included in the binary logistic regression models

Authors’ Response: We provided the said number [Page 14, Line 211].

Relevant articles related to suicide in Bangladesh:

Jordans et al. BMC Psychiatry (2014) 14:358. “Suicide in South Asia: a scoping review” DOI 10.1186/s12888-014-0358-9

Mashreky SR, Rahman F, Rahman A. Suicide Kills More Than 10,000 People Every Year in Bangladesh, Archives of Suicide Research (2013); 17:4, 387-396, DOI: 10.1080/13811118118.2013.801809.

Murad M. Khan. Suicide on the Indian Subcontinent. Crisis 2002; Volume 23 (3): 104–107. DOI: 10.1027//0227-5910.23.3.104

Authors’ Response: Thank you for proving some articles which are related to our current study. We have studied your suggested articles and used necessary information in Introduction and Discussion of our manuscript.

We would like to thank the reviewers for the valuable comments. We have revised the documents to the best of our ability, but we will definitely be happy to provide further improvement if there are further clarifications required.

With best regards

Dr. Md. Golam Hossain

Professor of Health Research Group

Department of Statistics, University of Rajshahi

Rajshahi-6205, Bangladesh

E-mail: hossain95@yahoo.com

6 Apr 2021

PONE-D-20-35857R1

Risk factors of suicidality among married adults: A cross-sectional survey in Rajshahi City, Bangladesh

PLOS ONE

Dear Dr. Hossain,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 21 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Vincenzo De Luca

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors,

I thank the authors for considering my suggestions and for revising the manuscript accordingly. While most of the comments provided in the first round have been addressed, some issues merit further consideration:

1. Abstract

• As a suggestion, if the authors need to save space, they could only include AORs without CIs and p values as these are provided in the results section.

2. Introduction:

• In my opinion, the authors could further synthesize the information presented in the introduction (instead of enumerating the results of each study) to make the case for the necessity of their work and guide the reader towards the objectives.

• Objectives 2 and 3 are very similar and could be combined.

3. Methods:

• I regret but from the provided information I do not understand how you calculated the sum score. For each observation, possible values are 0, 1 or 2. Therefore, I am unsure what represents the 75% cutoff.

• The authors could acknowledge as a limitation that substance abuse was entirely self-reported and no validated scales were used. Also, the authors could mention as a limitation that the type of substance abused is unknown.

• In the statistical analysis section (contrarily to the response provided to my comments) the authors do not mention that they used stepwise regression.

• Please provide in table 3 the number of observations that was used to run the multivariate model. The number of completed interviews is 761 and it is important to specify if the model ran on 761 observations or some observations were excluded because of missing values

• Since the present study is part of a larger project, I suggest that the authors provide this information in the methods section

• The authors stated that they revised table 1 (according to my suggestions) but the coding column was not changed, and percentages are not provided.

**********

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

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9 Apr 2021

Response to Reviewers

Journal Name: PLOS ONE

Tracking No. ( Manuscript ID): PONE-D-20-35857R1

Manuscript Title: “Risk factors of suicidality among married adults: A cross-sectional survey in Rajshahi City, Bangladesh"

Dear Editor

Thank you very much for providing reviewer’s comments/suggestions on our manuscript. We have modified and revised the manuscript accordingly, and detailed corrections point–by-point is given below:

Review Comments to the Author:

Reviewer #1:

I thank the authors for considering my suggestions and for revising the manuscript accordingly. While most of the comments provided in the first round have been addressed, some issues merit further consideration:

Authors’ Response: Thank you for your kind efforts for improving our manuscript. We appreciate your comments and suggestions on the manuscript.

1. Abstract

• As a suggestion, if the authors need to save space, they could only include AORs without CIs and p values as these are provided in the results section.

Authors’ Response: Thank you for your suggestion. We have deleted 95% CIs, and considered AORs and p-values, p-values have been considered for justification of significant.

2. Introduction:

• In my opinion, the authors could further synthesize the information presented in the introduction (instead of enumerating the results of each study) to make the case for the necessity of their work and guide the reader towards the objectives.

Authors’ Response: According to your advice, we revised some portions of the introduction section [Line 55-92].

• Objectives 2 and 3 are very similar and could be combined.

Authors’ Response: We have combined objectives 2 and 3 as 2 [Line: 119-120].

3. Methods:

• I regret but from the provided information I do not understand how you calculated the sum score. For each observation, possible values are 0, 1 or 2. Therefore, I am unsure what represents the 75% cutoff.

Authors’ Response: Authors’ Response: In our present study, suicidality was measured by addition of two items (i) suicidal ideation (yes=1; no=0) and (ii) suicide attempt (yes=1; no=0). We calculated the sum of score (the sum of score would be 0, or 1, or 2 for a particular respondent). We classified our sample into two groups; (i) No suicidality (sum of score 0; code 0), and (ii) Suicidality (Sum of Score 1-2; code 1). We have described this issue in Line: 167-170.

For another issue (cut-off point 75%), actually, we followed a publication where authors used a cut-off point at 75% of sum score of depression’ and a percentile of ≥75% of the sum score was considered as depression and <75% of the sum score as no depression”.

We have reanalyzed our data considering the categorical outcome variable, suicidality (Yes=1, No=0), and got same logistic regression results as we considered 75% cut-off points. We have deleted 75% cut-off point from text to avoid confusion [Line: 170-172].

• The authors could acknowledge as a limitation that substance abuse was entirely self-reported and no validated scales were used. Also, the authors could mention as a limitation that the type of substance abused is unknown.

Authors’ Response: We agree with you, and have put these issues in limitation [Line: 339-341].

• In the statistical analysis section (contrarily to the response provided to my comments) the authors do not mention that they used stepwise regression.

Authors’ Response: Actually, stepwise logistic regression model was not used in our present study, so we did not need to mention it in Statistical Analysis. We used multivariable (multiple) logistic regression model for analyzing our data, and mentioned it in Statistical Analysis[Line:185-186]. .

• Please provide in table 3 the number of observations that was used to run the multivariate model. The number of completed interviews is 761 and it is important to specify if the model ran on 761 observations or some observations were excluded because of missing values.

Authors’ Response: We have mentioned in Method [Line: 160-161], finally 708 samples were used in our present study. Since, we did not have missing values of any variable, we have mentioned (n=708) in the title of Table 3 and Table 2.

• Since the present study is part of a larger project, I suggest that the authors provide this information in the methods section.

Authors’ Response: We have mentioned this issue in Method [Line: 129-130].

• The authors stated that they revised table 1 (according to my suggestions) but the coding column was not changed, and percentages are not provided.

Authors’ Response: Earlier, you suggested, “Table 1-in my opinion this should be merged with results and contain percentages for each category (variable); providing the coding is less informative”. According to your earlier suggestions, we have revised Table 1 accordingly, and put it in Result section. Table 2 also has been revised.

We would like to thank the reviewer for the valuable comments. We have revised the documents to the best of our ability, but we will definitely be happy to provide further improvement if there are further clarifications required.

With best regards

Dr. Md. Golam Hossain

Professor of Health Research Group

Department of Statistics, University of Rajshahi

Rajshahi-6205, Bangladesh

E-mail: hossain95@yahoo.com

3 May 2021

Risk factors of suicidality among married adults: A cross-sectional survey in Rajshahi City, Bangladesh

PONE-D-20-35857R2

Dear Dr. Hossain,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Vincenzo De Luca

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I consider your manuscript a valuable addition to the existing literature. All the best in your future research.

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Reviewer #1: No

4 May 2021

PONE-D-20-35857R2

Risk factors of suicidality among married adults: A cross-sectional survey in Rajshahi City, Bangladesh

Dear Dr. Hossain:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Vincenzo De Luca

Academic Editor

PLOS ONE