Suicides in Our Little Red Dot – cause for alarm

Two weeks ago a mother was killed by her daughter who then took her own life  in a horrible suicide with her mangled body lying on the concrete pavement below the block of flats in Ang Mo Kio.

According to the latest statistics, there were 467 suicides in 2012 - nearly 30 per cent more than in the previous year - raising the national suicide rate from 8.13 per 100,000 resident population in 2011 to 10.3 in 2012. We do not have 2013 statistics, but we can assume it will be no better than that of 2012. The 2012 figure is the highest in 21 years, with the most significant increase coming from three age groups – the young, the middle aged, and the early senior aged.  What a sad waste of  lives . Could we have done something to at least save some of them?

Table  showing 2012 breakdown of suicides by age group (Adapted from SOS)

Every day, about for or five people in Singapore try to kill themselves, and at least one succeeds. According to police records, the number of reported  attempted suicides increased from 1,009 in 2011 to 1,090 in 2012.  The number of death arising from suicide rose from 8.1 per 100,000 population in 2011 to 10.3 per 100,000 in 2012. In 2012, the Samaritans of Singapore (SOS) handled more than 44,000 hotline calls, indicating the number of people contemplating suicide even if not attempting it. Other help organizations like Care Counselling Centre (Mandarin speaking call centre) and Singapore Association for Mental Health have also been receiving more than 2,000 calls for help during the same period.

 Singapore ranks 48^th out of 110 countries in terms of suicide rates as of 2012. A simple comparison with India with a population of 1.3 billion is ranked 46^th with a suicide rate of 10.5 per 100,000, can make us wonder why we have a high suicide rate when our population is only 5 million and our  GDP is 15 times more than that of India.

What is worrying is doctors and social workers say people attempting suicide appear to be getting younger and younger.  If we look at the statistics for  2012 (above table), of the 298 male suicides,  22% were below 30 years of age. Among the 169 female suicides,  21.7% were below 30 years of age.  Within this category, about  one-fifth of  the suicides were committed by teens.  A recent study conducted by three doctors examining suicide rates among teenagers stated that it's not stress over grades but friction with parents and breaking up with a boyfriend or girlfriend that act as trigger. The SOS which runs a help-line for troubled people, agrees with the findings and states that two-thirds of the callers aged below 19 were troubled by problems with family members. Problems with boyfriends/girlfriends or peers came second  and problems at school or work ranked third.

What triggers the decision to commit suicide is not easy to figure out, although there are tell-tale signs of a teen near the brink, say counsellors. Sudden change in behaviour, like loss of interest in their favourite activities and  at school , is one indicator. Those who have attempted suicide and suffer from depression are most at risk. But the danger signs are “ when they write farewell notes, call up friends to say goodbye, give away treasured belongings and behave secretively”, said Dr Fung, deputy chief of IMH's department of child and adolescent psychiatry, and one of the three doctors who did the research. Professor David Shaffer, head of child and adolescent psychiatry at New York's Columbia University, who has studied global teen suicide trends for 20 years, said most of the teens who commit suicide suffer from depression for six months to two years before their deaths.

Suicides among the young adults (20 – 29 years age group) saw the biggest increase in  2012. The number  doubled that of 2011.  SOS says common problems for this age group “involved stressful life events and interpersonal relationship issues”. These include unemployment, stress over studies or work, financial worries, family life, struggles with social interaction and feelings of loneliness. SOS Executive Director Christine Wong believes that people in their 20s are exploring their identity, discovering new responsibilities and building their career and their family, and some of them cannot cope with the stress. Adding to this burden, young people tend to hide their pain and that they may not know where or who to approach for help.  Dr Chia Boon Hock,  a psychiatrist says “life is tougher compared to the previous generation because now there is too much to want, too much to need and too much to buy”.

The second group of suicides that reflects a sad situation is the adult group with age ranging between 30 and 49. Male suicides in this age range amounted to 94, (32 %) of total male suicides in 2012. Female suicides in the same age range totalled 55 (or 33%) of total female suicides. This age range would comprise people who are working or have worked for some time and probably  took  their own lives because they see no possible solution  to their mounting personal problems.  Most times  the psychological turmoil they experience could be more tormenting than the problems they face. According to Dr Chia ,  factors such as employment, debt, marital problems, legal problems and mental illness are contributory causes. Suicidal people” in their 30s and 40s are largely driven to suicide  by issues such as failed relationships and debts”, says Ms Esther Lim, head of medical social services at the Singapore General Hospital. Most attempted suicides which end up at hospitals involve an overdose of medication. Some try to slash their wrists.

Among the third group, comprising the seniors and elderly, suicides are due to gradual physical disability and suffering  and are aggravated especially if coupled with the lack of adequate community and family support.    The suicide mortality rate among those aged 50 years and above is about 6.45 times higher than that seen in the rest of the population.  Elderly people who think about suicide often feel lonely, suffer from a chronic illness, or feel like they do not have a purpose in life. It has been estimated that by 2030, only 45 per cent of persons over the age of 65 in Singapore will be living with families . Thus, it is unrealistic to expect older persons to rely on families as their main source of care and support. It would also be socially irresponsible to neglect older members of our society who cannot rely on familial care.  The 2011 IMH study on the state of mental health in Singapore  identified three major mental illnesses affect a large number of Singaporeans. One in 17 people in Singapore have suffered from Major Depressive Disorder at some time in their lifetime, while Alcohol Abuse and Anxiety Disorder  affected one in 32 and one in 33 people, respectively. The study also found out  that the majority of the mental illnesses occurred by the age of 29 years. And most of the people with mental illness were not seeking help. This can explain why the age ranges of 30 -49 and 50 - 69 show a significant number of suicides.

However suicide rates among the elderly  are showing a significant drop over the last five decades in Singapore. In 2012, elderly males (70 years and above)  totalled 40 (13.4%) of total male suicides, while elderly females suicides numbered 25 (14.8%). According to experts , the main reason for this is that the population has become wealthier and  with schemes such as CPF, Medisave, Medifund  and medical subsidies from the Government, the elderly are better taken care of, driving less to suicide.

Overall, males appear to be more at risk of suicide, regardless of the age group. A total of 298 men committed suicides in 2012, about 1.75 times the number of women. “Men may not openly express their problems or seek support or professional help,” explained Ms Wong of SOS.  She says that individuals with fewer coping mechanisms, weak family support and social networks may be more vulnerable when they are overwhelmed by feelings of desperation and hopelessness.

In the 2011 study of Singapore’s state of  mental health by IMH,major depressive disorder (MDD) was the most common mental illness in Singapore. 5.8% of the adult population in Singapore suffer from MDD at some time in their lifetime. Depression was also associated with chronic physical illnesses. About half  of people with MDD had at least one chronic physical illness. About 3.1% and 3.6% of the population suffer from alcohol abuse and Anxiety Disorder respectively at some time in their life. Looking at these figures, in our tiny city state, we have more than half a million people (young and old) suffering from depression, anxiety disorder and alcohol abuse amongst us, and they could be driven to suicide at any time, if they do not seek help. Isn’t that worrying?

Cause for alarm

According to the World Health Organisation one million people commit suicide every year worldwide, accounting for more deaths than wars and murders put together. Isn’t it surprising that world leaders and the United Nations members spend so much resources in trying to solve trans-national conflicts, wars and crimes, yet there has been no recognition or committed resolution of the suicide problem.

In our dear little Red Dot, suicides account for about  2.5% of total deaths every year officially. Suicide is one of the top ten causes of death in Singapore.  The coroner decides if a death is natural, unnatural or a suicide. It is possible that some suicides may be classified as unnatural deaths, especially if there is no clear evidence  like a suicide note. This may not sound significant, but in our city state, every life counts especially when our TFR is falling by the year, and human resources are our key strength for economic success. But looking at the statistics revealed in the IMH study, one can see the potential danger of increased suicides unless mental illness is managed more effectively.

Tackling the Problem

The Ministry of Health states  that  hospitals do provide crisis intervention for patients who have attempted suicide. Some of the actions taken include “elimination of acute suicide danger (eg: hospitalization, sedation, crisis-intervention), adequate treatment ,  follow-up care for those with high suicide risk and counselling and support groups for patients both within the hospital and community settings”.

The Health Promotion Board (HPB) has been conducting  various mental health promotion and education programmes “to promote mental well-being among children, adults and seniors”.  In 2011, more than 40 initiatives and activities were organised in schools, workplaces and community settings, reaching out to some 170,000 students and members of the public.  MOH also mentions that access to mental health services has improved.  IMH’S community mental health teams (CMHTs) provides  rehabilitation for stable patients; and CMHT also operates a Mobile Crisis Team which comprises a 24-hour hotline giving information and advice, and a Home Visit Team that helps to de-escalate stressful situations that patients face in their homes. The GP Partnership Programme helps GPs better manage persons with mental illness in the community. Other programmes include the Community Health Assessment Team (CHAT), launched in 2010 and led by the Institute of Mental Health. CHAT includes efforts to reach out to distressed youth from post-secondary education institutions such as polytechnics and the Institute of Technical Education or ITE. Perhaps what is lacking is awareness. These preventive and proactive programmes need to be publicised and promoted more often to inform the layman.

Can we help?

Non-governmental organizations like SOS, Care Counselling Centre,  SAMH and others are also doing their part to save as many lives but they can only help if a suicidal person reaches them. It behoves on us  then, to play our part to seek and support proactive solutions to complement what the government and NGOs are doing. Most of us are generous with our donations, but very few are really keen  to help suicidal people.  A common reason many cite is that we are not sure if our help would be deemed interfering in others’ personal lives or that we do not know when or how to help. There is also a fear that we may get into issues of relationship and dependency once we offer  help. All these reasons are purely excuses and if  we know we can save a life in our encounter with a  suicidal person, nothing should prevent us from doing it. The fact that there are many “walking wounded” amongst us at work, on the trains, on the buses, and on the walkways, should spur us to act, to do something, especially if we know the “walking wounded” someone.

There are numerous helping guides to  recognizing  suicidal persons and simple key steps to saving them. The following guide, adapted from the Montana Suicide Prevention Lifeline, USA, is easy to understand and remember  and apply in the event of a need :

 WARNING SIGNS

1. Expressed or communicated threat to hurt or kill him/herself, or talking of wanting to hurt or kill him/herself; and/or looking for ways to kill him/herself.
2. Increased alcohol or drug use.
3. No reason for living; no sense of purpose in life, start giving things away because there’s no purpose in keeping anything, no reason to maintain their hygiene.
4. Anxiety, agitation, unable to sleep or sleeping all the time, difficulty concentrating.
5. Feeling trapped (like there’s no way out ) or sense of hopelessness.
6. Withdrawal from friends, isolating from family and society.
7. Acting reckless or engaging in high risk activities, seemingly without thinking, impulsive.   
8. Dramatic mood changes, flat affect, depressed mood, acting out of character.
9. Rage, uncontrolled anger, seeking revenge, irritable.
10. Loss of interest in school, studies, activities and hobbies ( among young suicidal persons).

THREE STEPS TO SAVING A LIFE

1. Ask the question  - the direct approach is the best approach. Here are some examples of how to ask the suicide question :

(a) “You know, when people are as upset as you seem to be, they sometimes wish they were dead.  I’m wondering if you’re feeling that way, too?”

(b) “You look pretty miserable, I wonder if you’re thinking about suicide?”

(c)  “Are you thinking about killing yourself?” 

NOTE: If you cannot ask the question, find someone who can.

 2. Provide hope

HOW TO PERSUADE SOMEONE TO STAY ALIVE

(a)   Listen to the problem and give them your full attention

(b)   Remember, suicide is not the problem, only the solution to a perceived insoluble

       problem

(c)   Do not rush to judgment

(d)    Offer hope in any form

Then Ask:

(a)   “I don’t want you to kill yourself, I want to help”

(b)    “Will you go with me to get help?”

(c)    “Will you let me get you some help?”

(d)    “Will you promise me not to kill yourself until we’ve found some help?”

3. Take them directly to help

(a) Suicidal people often believe they cannot be helped, so you may have to do more.

(b) The best referral involves taking the person directly to someone who can help ( police, Hospitals, IMH Mobile Crisis Team). 

(c) The next best referral is getting a commitment from them to accept help, then making the arrangements to get that help.

 

End Note

Consequences of Suicides –

(a)   Cost to Society

Suicide and suicide attempts take an enormous toll on society. We do not have figures to understand cost of suicides in Singapore. In the US,suicide costs society approximately $34.6 billion a year in combined medical and work loss costs. The average suicide costs $1,061,170.(CDC cost estimates based on 2005 data).

 (b)   Survivors

• A survivor of suicide is a family member or friend of a person who died by suicide.
• Surviving the loss of loved one to suicide is a risk factor for suicide.
• Surviving family members and close friends are deeply impacted by each suicide, and experience a range of complex grief reactions including, guilt, anger, abandonment, denial, helplessness, and shock.

 (c)   Economy

The impact to the country may not be visible but there is a greater need to provide infrastructre, specialist manpower and carefully planned programmes to reduce the incidence of suicides. The government and NGOs would need additional resources and money to fund these programmes. The other cost to the country is the loss of potential human resources and talent with each suicide, given our limited human capital.

 The Need to Act

 Suicide is not just something we hear about in the headlines. It is something that affects us all on a personal level. In the US, almost one in five people have been personally impacted by a suicide. You never know when someone you care about may become at-risk. It is, therefore, important tounderstand  what goes on in the mind of someone who is suicidal, so we can help them win their battle against the distorted perceptions that are leading them toward this ultimate act of self-destruction. If you or someone you know is in crisis or in need of immediate help, call:

 Helplines

Samaritans of Singapore (SOS): 1800 - 221-4444

Family Service Centre: 1800-838-0100

Singapore Association for Mental Health: 1800-283-7019

For the elderly

Seniors Helpline: 1800-555-5555

For Mandarin speakers

Care Corner Mandarin Counselling Centre: 1800-353-5800

For youths and children

Touchline (Touch Youth Service): 1800-377-2252

Tinkle Friend: Children can call 1800- 274-4788 on weekdays