April 22, 2009
THE ST INTERVIEW
Warning: Suicide peak ahead
If the recession worsens, the incidence of people taking their lives may rise. Suicide is alsoa sad reflection of a society's failure to help them as needed. -- Suicide expert Chia Boon Hock
By Susan Long
IF THE downturn deepens, Singapore should brace itself for a rise in suicides. And it should do all it can to prevent the increase from starting now, warns Dr Chia Boon Hock.
Singapore's resident suicidologist, who has spent 40 years collecting and studying suicide data, says there have been four major suicide peaks here over the past 100 years.
Notably, three of these happened just after major recessions, when financial woes and unemployment took their toll. The other came in wartime.
The first was during the 1906 to 1910 Bankers' Panic financial crisis, which saw the suicide rate surge 71 per cent to 11.3 per 100,000 people.
The second peak was in the aftermath of the Great Depression, from 1936 to 1940, when the toll swelled to 15.8 per 100,000 people.
The third, from 1941 to 1945, during the tumultuous Japanese Occupation, saw a record 16 per 100,000 people kill themselves. The fourth saw 12.8 per 100,000 people ending it all from 1986 to 1990, just after the 1985 recession.
Apart from these peaks, Dr Chia says Singapore's suicide rate has been on a downward trend and remained relatively stable at about 10 to 12 per 100,000 people per year. That translates to about 400 deaths a year, or one a day.
But if the recession worsens, the 73-year-old psychiatrist says that the incidence of people taking their own lives may be headed for another crest.
Since it typically takes up to six months for a coroner's inquest to decree a death a suicide and a further year to collate national data, the magnitude of the problem will surface only in two years time. This being so, he says it is important to sound the alarm bells early.
Throughout Asia, countries are already bracing themselves for a suicide spike. In South Korea, commuter train operators are installing doors to block access to railway tracks because there are more subway jumpers. In Japan, suicide hotline numbers have been posted at suicide hot spot Mount Fuji. Hong Kong has run special hotlines since October for crisis-related depression.
The United States is also predicting a rise in suicide rates just like during the Great Depression. Suicide rates rose from 14 to 17 for every 100,000 Americans from 1929 to 1933, as unemployment rates increased from 3.2 per cent to 24.9 per cent within the same period.
Similarly, there is a well-established link between unemployment and suicides here. Citing data from 2000 to 2004, Dr Chia notes that suicide rates for the jobless were about 20 times higher than those of the employed.
'In Singapore, no social security system exists. Losing one's job is associated with a great loss of face and identity. Charity organisations cater only to the very poor and very sick.
'The able-bodied unemployed may find it necessary to rely on their savings or on the generosity of friends and family. The social stigma, coupled with stress especially of an older person trying to find a job quickly, while supporting a household, is enormous,' he says.
In fact, even in good times, money plays an inordinately large role in suicides here, especially for men and the middle- aged. At least 27 per cent of suicides here typically are financially motivated, he says.
About 26 per cent of Singaporean men and 14 per cent of women who committed suicide from 2000 to 2004 did so because of financial problems, ranging from debts, losses, gambling, unpaid credit card and medical bills and being hounded by loan sharks.
But he is not particularly worried about the rash of 'honour' suicides among the world's most financially powerful, such as London financier Kirk Stephenson flinging himself in front of a train, French aristocrat Rene-Thierry Magon de la Villehuchet swallowing pills and slitting his wrists, and Chicago real estate mogul Steven Good shooting himself in his Jaguar, after their fortunes soured in recent months.
'These are hard-driving Type A personalities who wanted it fast but lost it all and found the shame too great to bear,' he says.
In reality, the incidence of rich people committing suicide here is rare because 'they have too much to live for'. Those at the lower socio-economic levels, who worry constantly about their jobs, are more vulnerable. Although their identity is not attached to their wealth, it is attached to their being providers for their families, he notes.
Another group at risk are the underemployed, such as those recently laid off, now struggling to support themselves in the service sector and cope with diminished circumstances. Between 2000 and 2004, he notes, a total of 45 self-employed people killed themselves, along with 42 in sales positions, 40 labourers, 24 taxi drivers and 19 cleaners.
Equally vulnerable are retirees who have lost their life savings in the market upheaval. He is currently seeing a few depressed patients in this predicament.
'Overnight, their nest eggs have been wiped out. There is no chance of recovery. If they are struck by a major illness, it will tip them over the edge.
'What aggravates the problem is that the reason why most elderly Singaporeans kill themselves, besides prolonged pain and suffering, is dwindling finances and the feeling that they are a burden to their family. It's an Asian thing. Even if their kids have money and want to give it to them, they feel shy to take it.'
This is why he is apprehensive about the news that pro-euthanasia group Exit International has been allowed to hold a workshop here in May, where information on how to end life painlessly will be dispensed. He fears the momentum towards legalising euthanasia here may lead to more elderly folk feeling obligated to make an early exit.
'There is potential for abuse, especially by third parties. It can be misused by relatives with mixed motives. It needs to be studied very carefully and approved only selectively on a case-by-case basis,' he cautions.
Over the years, he notes the Government has done a laudable job in bringing down elderly suicides, from a high of 51.7 per 100,000 in 1972 to a low of 23.2 per 100,000 in 2004. Among 62 countries worldwide, Singapore's suicide rate for those aged above 65 now ranks a more acceptable 24th for men and 28th for women.
In recent years, he notes economic upheaval has, at most, had a minor effect on the suicide rate here, thanks to government measures to arrest unemployment and mitigate hardship. No surges were noted after the 1997 Asian Financial Crisis, 2001 recession and 2003 Sars epidemic. Suicide rates then were a moderate 9.1, 8.6 and 8.3 per 100,000 respectively.
This compares favourably to South Korea, where suicide rates nearly doubled during the Asian Financial Crisis to 19.9 in 1998.
In fact, he says Singapore's tumbling suicide rate now compares favourably with many other nations. Out of 62 countries and territories worldwide, Singapore's suicide rate now ranks 37th for males and 27th for females overall. It trails far behind South Korea (24 per 100,000), Japan (23.1 per 100,000), rural China (22.2 per 100,000) and Hong Kong (18.6 per 100,000).
But there is no room for complacency. While he lauds the Government's recent decision to inject $35 million over the next three years to shore up emotional resilience here, he says that beyond state efforts, people should do more to look out for each other on an everyday basis.
'Suicide is not only a desperate final act for those who find life hopeless and bleak because of their inability to cope, general social stresses, mental and physical illnesses. It is also, indirectly, a sad reflection of a society's failure to help them as needed,' he says.
Because attempting suicide is a crime, it is carried out in secret. Out of 1,717 suicides from 2000 to 2004, he notes that only two contacted suicide hotlines prior to the deed.
'Although hotlines are good for building awareness, providing support for the bereaved and counselling the distressed, whether they prevent suicide, I've my doubts. If people make up their minds to kill themselves, they don't need to consult anyone. It is up to people around them to detect their plan. Even if you ask them tactfully and directly, some may evade the issue.'
But he notes that Singaporeans, being pragmatic, can be relied on to seek medical help to alleviate symptoms of stress and anxiety, which could be a prelude to suicide.
'If they can't sleep, they see a doctor for sleeping pills. Likewise if they have chest pains, cannot sleep and eat. This is why they might broach suicide if doctors ask them diplomatically.'
This is where, he says, general practitioners, nurses, school counsellors, social workers and religious leaders, who are trained to be alert to early signs of suicide, can come in. This can help make up for the shortfall in psychiatrists in Singapore - currently about one for every 38,461 people - as life here becomes more stressful.
He notes that 27 per cent of those who took their own lives from 2000 to 2004 suffered from a major mental disorder. Almost all of them - 97 per cent - had sought psychiatric help prior to the deed.
Yet their blood levels at death showed that most were not taking their prescribed medicines, not being treated adequately, or not responding to the treatment given.
'This suggests that what failed them was not a lack of services, but that follow-up care was not good enough. There was probably no continuity of care and no ownership of their treatment, without a single case manager responsible for their care.'
He says that if there is a concerted effort at all levels to beef up care and training for all to be alert to early suicidal signs, it could cut suicides by 20 or more yearly. 'Cutting down Singapore's suicide rate by up to 10 per cent is probably the best-case scenario in these circumstances,' he says.
Because in the suicide stakes, he says, Singapore should do all it can to remain an underperformer - and be proud of it.
3 signs the suicidal leave
VERBAL WARNINGS: These are given in almost half of all suicides. These consist of expressions that 'life has no meaning', fatigue or bidding loved ones a final farewell. The young sometimes issue verbal threats like: 'If you do not love me, I will kill myself.'
PRE-SUICIDE PLANNING: This is seen in about 10 per cent of suicide cases. It involves tidying up one's affairs, such as finalising a will, leaving funeral instructions, sorting out finances, examining burial sites, studying the dimensions of the window they intend to jump from. About one-quarter of suicides here, usually the young, single and local-born, leave behind suicide notes. In some cases, they also send out text messages or make phone calls prior to the deed.
BEHAVIOURAL CHANGE: This is seen in only less than 5 per cent of cases. Changes include sudden calm or euphoria, excessive spending, generous gift-giving, sudden withdrawal, or a refusal to eat days to weeks before the event.
Sage Counselling Centre: 1800-555-5555
Care Corner Family Service Centre: 1800-222-0000/1800-353-5800 (Chinese-speaking)
Samaritans of Singapore: 1800-221-4444
On the upside of a downturn
'This recession is good for making Singaporeans more resilient. It's a wake-up call. We seldom face hardship, the Government spoils us with lifts on every floor, covered walkways. Hopefully, it will teach us to be more frugal, less complacent and help us realise that things don't come easy, we've to work for it.'
On travelling light
'I live in a small shophouse in Joo Chiat and rent out my bungalow. Although I can afford a car, I go around by bus. I eat at hawker centres and exercise frequently. It's a simple but enjoyable life.'
On the state of mental health here
'We live in a very stressful society where the costs of living are sky-high. Singapore is a great place to live if you are young, intelligent, rich, successful, capable and healthy. But the average person isn't all that.'
A life spent studying death
DR CHIA Boon Hock, 73, is Singapore's resident suicidologist and a walking repository of research on the motivations, methods and meanings of suicide.
He has spent his life poring over coroner's reports, collecting data and trying to demystify what drives people over the edge.
He recently finished analysing hundreds of suicide letters left behind by Singaporeans between 2000 and 2004 for the renowned journal, Archives Of Suicide Research. He also contributed a chapter on Singapore to the 2008 book, Suicide In Asia.
In 1968, he became the first psychiatrist here to go into private practice. Besides a medical degree from Hong Kong University, he also has a doctorate on suicide from the University of Singapore.
He estimates that about 90 of his patients have killed themselves out of the 5,000 he has treated over a 20-year period.
Now semi-retired, he works an 11-hour week at his private practice, plays golf, practises the piano, learns Mandarin, does gardening, plays with his three grandchildren and analyses data on suicide as a hobby.
He is married to a housewife. They have two children who are both doctors.