Adverse childhood experiences and suicidality in low-income and middle-income countries: a systematic review and meta-analysis

Introduction Suicide is an important public health problem with a complex aetiology; this includes adverse childhood experiences (ACEs). Common to suicide and ACEs research is a lack of evidence from low-income and middle-income countries (LMICs). This review aims to evaluate associations between ACEs and suicidality in LMICs. Methods In this systematic review and meta-analysis, a search for articles investigating associations between any ACEs and suicidal outcomes in LMICs was conducted using Medline, Embase, PsycINFO, CINAHL and Web of Science on 2 December 2022; updated on 14 January 2025. Cross-sectional or cohort study research articles investigating ACEs prior to age 18 and using population-based, probabilistic or total population, sampling were eligible for inclusion. Suicidal outcomes across the spectrum were eligible for inclusion. Identified records underwent two-step screening by two independent reviewers; data extraction and risk of bias assessment using Joanna Briggs Institute Critical Appraisal tools were also completed in duplicate. Random-effects models were used to calculate pooled ORs. Articles that could not be meta-analysed were narratively synthesised. Reporting of this review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. Results Ultimately, 118 articles were included; all were of low or moderate risk of bias and none reported on suicide mortality. Six ACEs were significantly associated with increased odds of suicidal outcomes: (1) bullying-victimisation, (2) emotional, verbal or psychological abuse victim, (3) parental separation, divorce or death, (4) physical abuse or violence victim, (5) physical attack victim and (6) sexual abuse victim. Significant ORs ranged from 1.19 to 2.61. Positive associations were found across subgroup and sensitivity analyses. Narrative review found statistically significant positive and non-significant associations between ACEs and suicidal outcomes. Conclusions ACEs are associated with suicidal outcomes in LMICs, highlighting the need for early intervention strategies and multisector public health approaches to reducing ACEs and their potential impacts.