Mental health: The way forward

09 Sep 2014 / 19:17 H.

    MANY of us were saddened by the news of Robin Williams' death due to suicide after a long, debilitating struggle with severe depression. The Oscar-winning actor and comedian had warmed the hearts of millions worldwide with his endearing and inspirational performances in movies such as Good Morning Vietnam, Mrs. DoubtFire and Good Will Hunting.
    His tragic loss forces us to confront the reality that even a cinematic icon symbolising the resilience of the human spirit can still succumb to the inner demons of this terrible affliction. The shock resounding throughout the entertainment industry in the wake of his death, as well as the heartfelt global outpouring of tributes and condolences are both sombre testimonies to the major impact that suicide can have on the families of the survivors and the larger community. One of the indirect positive outcomes that the initial media frenzy over his death has generated is the refocusing of wider public attention on the oft neglected and taboo topic of suicide.
    Research into suicide has determined that it is a complex issue which involves the interplay of a variety of psychological, social, biological, cultural and environmental factors. Some of the key risk factors which contribute to suicidal ideation and attempts are mental illnesses, substance abuse, chronic illness, severe social isolation, traumatic relationship conflict and loss.
    A simple way of looking at it is to think of suicide as a last-resort coping mechanism when someone is overwhelmed with a variety of burdens and stresses that he or she is no longer capable of bearing alone. Research studies have repeatedly shown that social isolation can increase the risk of suicide and, conversely, that having strong human bonds can be protective against it. Connectedness is therefore crucial to individuals who may be vulnerable to suicide, and reaching out to those who have become disconnected from others and offering them support and friendship may be a life-saving act.
    In 2012, the Malaysian National Suicide Registry recorded 1.3 deaths by suicide for every 100,000 people. Although this suicide ratio is much lower compared to countries like Hong Kong, South Korea or Japan, many academics and NGOs believe that the actual figure is much higher due to under-reporting for various reasons.
    This most likely are the social stigma attached to suicide, religious concerns and legal problems. In the past year or so, there have been quite a number of high profile suicide cases involving students and young adults reported in the media, leading to a wide variety of responses and reactions from the general public. Some individuals who have been struggling with suicidal thoughts have bravely stepped forward into the limelight to share their ordeal; an example of this is the moving testimony by Stella Lee in the article "Beyond Barriers: Suicide on her mind" published on Aug 21.
    Suicide is a major global public health problem. Statistics from the World Health Organisation (WHO) indicate that every year, over 800,000 people die from suicide. Overall, it is estimated that during 2012 for each adult who died of suicide there were over 20 others who made suicide attempts. The number of lives lost through suicide exceeds the number of deaths due to homicide, terrorist acts and war combined.
    This is truly a sobering thought which should give all of us pause, particularly when we realise that some of these suicides could have been prevented with an appropriate understanding and approach to the problem. In recognition of the magnitude of this tragedy, WHO has designated Sept 10 as World Suicide Prevention Day: an annual event that has run since 2003 to focus public attention on and celebrate global efforts and success in attempting to mitigate this crisis.
    World Suicide Prevention Day in 2014 is significant because it marks the release by WHO of the World Suicide Report. The report follows the adoption of the Comprehensive Mental Health Action Plan 2013-2020 by the World Health Assembly, which commits all 194 member states (Malaysia being one of them) to reducing their suicide rates by 10% by 2020.
    The World Suicide Report presents the most recent data from countries across the world on this issue; including evidence for promising key interventions that can reduce suicide attempts as well as successful national suicide prevention strategies in a number of countries. Some of these proven interventions include removing barriers and stigma associated with accessing mental health care, removing or limiting access to means of suicide (eg pesticides, poisons, medications), responsible reporting of suicides, raising public awareness about mental health disorders and suicide and expanding mental health care outreach. Some, or all of these, can form the backbone of the implementation of a national integrated mental health policy.
    The government has commendably launched a five-year National Suicide Prevention Strategic Action Plan that commenced in 2012 which reflects some of the prescriptions above. One of the key efforts in this plan is to shift mental health treatment from hospitals to community mental health centres to increase availability to the general public.
    The use of non-specialised health professionals to increase support to suicidal individuals via online and telephone counselling services (such as the Befrienders) is a core part of this outreach effort. The Health Ministry also intends to target a three-fold increase in the ratio of psychiatrists to the population, from the current 1:150,000 to the ideal of 1:50,000.
    There are, however, some areas where further progress can, and should, be made on this issue in our country. One key observation of this World Suicide Report concerns the legal status of suicide and its effects on suicide prevention in these member states. Of 192 independent countries and states investigated, 25 have specific laws and punishments for attempted suicide; Malaysia being one of these.
    Under Section 309 of our Penal Code, those who survive a suicide attempt or parasuicide, face up to one year in jail or a fine, or both, if convicted. The rationale for the preservation of this antiquated law inherited from our colonial masters is that its removal may encourage more suicide attempts. Yet to date, there are no data or case reports that indicate that decriminalisation increases suicides.
    In fact, suicide rates tend to decline in countries after decriminalisation; for eg in the majority of developed countries such as Germany, France, the Netherlands, Austria, Sweden, Denmark, Finland and Canada. In recognition of this fact, there was an attempt to review this controversial law by the Malaysia Law Reform Committee in 2012.
    Understandably, there are a variety of cultural and religious factors that also have to be taken into account in considering its repeal. Also, in practice, the law has rarely been invoked although there have been many cases where the authorities actively intervened to foil a suicide attempt. Nonetheless, when suicide is considered a criminal act, suicide attempts are often hidden and suicide deaths are unreported, thus giving the false impression that suicidal behaviours are less prevalent.
    If the government is serious about addressing the issue of suicide and its underlying causes, such information is vital to guide its efforts accurately. The right way forward will thus have to balance the sensitivities of the racially and religiously diverse communities of our country on one hand with appropriate outreach efforts to high-risk groups.
    Befrienders KL (go to is organising a public forum to address this important issue on Sept 27 at UEM Learning Centre PJ. Admission is free but seating is limited.
    Victor Tan
    Board Member
    Befrienders KL

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