Suicide cases in Singapore highest amid COVID-19 pandemic

Suicide is an international public health problem.?According to Channel News Asia, Singapore reported 452 suicides last year, the nation's highest count since 2012, amid the isolation and psychological distress brought about by the COVID-19 pandemic.?

The increase was observed across all age groups but in particular the elderly, which recorded the highest number of suicides since 1991. Among people aged 60 and above, a total of 154 took their own lives. This was a 26 per cent increase from 2019. In the other age groups - youths aged 10 to 29 and adults aged 30 to 59 - the number of suicides rose by 7 per cent from 2019. Overall, the number of suicide deaths rose to 8.88 per 100,000 residents, up by 0.88 when compared to 2019.

Risk Factors:

1.Those with certain personality types are at risk (28%). Most typically they tend to be proud, secretive, lonely people with low self-esteem, a tendency to worry unnecessary and poor problem-solving skills. These personality types find it difficult to relate to other, share problems and seek solutions.

2. People with addictions are also at risk. These include those with drug addiction (10.5%), alcoholism (5%), gambling problem (5%) and deviant sexuality (0.6%).

3. Mental illness is also a major risk factor and is associated with suicide in 58%.

MYTHS OF SUICIDE

1. People who commit suicide must be insane

People who commit suicide are often in ‘anguish’. About 25% of suicide victims leave behind suicide notes which provide some insight into the emotional state of victims just before they commit suicide. In a review of 398 such notes left behind in the years 2000-2004, 45% contained negative emotions such as a sense of despondency/agony (60%), followed by feelings of emptiness, guilt, shame, anger and hopelessness. Anger, when expressed, was often directed inwards; ‘I am useless, shameful, un-filial, a bastard’. In many cases, victims expressed sadness, care and concern about their loved ones; ‘Please look after mother after I’m gone, ‘Study hard. Listen to your mother’, ‘Don’t forget your medicine‘, I’m sorry. Please forgive me. Most knew that what they did was selfish and wrong, but simply could not find a solution to their problems, or cope with their emotions; ‘I am in terrible pain, I can’t describe my suffering’. To them, the non-existence or the next life may be better; ‘I am going to Heaven. I hope my wife is there, ‘I hope we will be together again in the next life, ‘That’s it. The end’. Only a few notes were markedly incoherent, irrational and delusional.

2. People commit suicide on impulse and without giving warning and people who talk about committing suicide don’t do so.

From a survey of suicide cases, 45% of suicide gave some form of verbal warnings (talked or hinted about committing suicide) prior to doing so. Most suicide victims have thought about committing suicide, sometimes for years before the actual act and 23% would have attempted suicide before. The suicide act often involves some planning (e.g. acquiring the means necessary to suicide, planning the timing of the act, organizing how their possession should be distributed, and even organizing their own burial). One elderly lady elaborately arranged her suicide so that it appeared that she fell whilst cleaning the window, and left a letter instructing her family what to tell the police so that no stigma would be attached to the family.

3. One should not try to discuss suicide with depressed patients, it might give them ideas or upset them enough to `push them over the edge’.

On the contrary, talking about suicide to a depressed patient often bring relief to him/her. It makes the patient feel that the doctor really understands him and thus will be more able to help him to relieve his `anguish’. In assessing suicide, it may be necessary to directly ask a person: ‘Have you thought about committing suicide?’ ‘What plans have you made?’ If the answer is affirmative especially with a detailed suicide plan mentioned then the risk of suicide is high.

4. Improvement following a suicidal crisis means the suicide risk is over.

Patients with major mental illness often suffer from relapse/s for various reasons. Each relapse dampens morale and further increases suicide risk. Suicide risk factors may also fluctuate over time. Therefore, even after the crisis has abated, we must remain alert and watch out for new dangers. In some cases, there may be a paradoxical uplift in mood prior to a person committing suicide. This happens when a person has finally decided to end the turmoil he is suffering by killing himself. A solution to his problem found, the patient is at peace and even happy; and surprises everyone by committing suicide several days to weeks later.?

FIND WAYS TO CONNECT

"Some elderly people live alone and lack the support to cope with the pandemic", said Adjunct Associate Professor Lee Cheng, clinical director at the Institute of Mental Health's Office of Population Health.

"People should find as many ways as possible to connect with the elderly who are lonely and socially isolated, said Associated Professor Helen Ko, who teaches gerontology at the Singapore University of Social Sciences. "Very often, most elderly persons want to hear a human voice and they long to hear the familiar voice of a loved one. For those who are not digitally savvy, please be very patient as they may need more time to pick up digital skills," she said.

When we deal with a suicidal patient, however, the consequence of a mistake can be lethal, it is imperative that we be comprehensive in our approach, and use both demographic and clinical factors in our suicide assessment.

12 general principles deserve repeating:

1. Do a full assessment and document your findings.

2. Assess demographic, social and clinical risk factors

3. Assess the subject’s mental state. Understand their emotional turmoil.

4. Talk with relatives and friends to gain further insight, and

to assess the degree of family and community support available.

5. Built a rapport with the patient and the patient’s family.

6. Understand that there are push-and-pull factors that influence patients to risk of suicide, and try to maximize pull factors while minimizing push factors.

7. Ask the patient if he/she has thought about committing suicide, have made plans or have previously attempted suicide before.

8. Limit assessment to suicide means. When dealing with very disturbed patients, this may include putting grills on their window, having a lock installed to prevent exit from flat, limiting the supply of antidepressants, placing medication with relatives for safe-keeping, and locking their own doors when asleep at night.

9. Find the right combination of medication and dose for patients. This often involves starting low and increasing or adding medication till the right dose is found. Often, there is a combination of depression and agitation, and it is sometimes useful to prescribe a low dose of a major tranquillizer to decrease agitation and help patients sleep. When prescribing medication, also consider factors like cost, dosage and side-effects of medication which may influence compliance.

10. Reassess the patient closely to monitor progress. In certain cases where risk is extremely high, the patient may need to be admitted for more intensive care.

11. Utilize and mobilize your team. If you have the benefit of a team, use it. Dealing with suicidal patients can be stressful and emotional draining. Working as a team spreads the emotional burden and provides you with greater support. That said, it is important that there is clear communication on the roles and responsibilities of each team member, and that one person would be ultimately responsible for coordinating patient’s care.

12. Remember suicide risk is not over once the crisis is past. Don’t let your guard down. Be vigilant.

Interested to become a counsellor? Aventis School of Management offers both Graduate Diplomas and Master's programmes in counselling. Find your possible pathways here!

Sources: https://www.channelnewsasia.com/news/singapore/suicide-highest-record-elderly-mental-health-isolation-covid-19-15179528

https://www.cfps.org.sg/publications/the-singapore-family-physician/article/339_pdf