ForensicMedicineServices PsychiatryandMentalHealthServices MinistryofHealthMalaysia

National Suicide Registry Malaysia

PRELIMINARYREPORT: JULYDECEMBER

2007
AJOINT PROJECTBY DEPARTMENTS OFFORENSIC MEDICINEAND PSYCHIATRY& MENTAL HEALTH

Editedby: NorHayatiAli,AbdulAzizAbdullah Withcontributionsfrom: Dr.MohamadShahMahmood,Prof.T.Maniam,DatoDr. BhupinderSingh,DatoDr.SuarnSingh,Dr.JamaiyahHaniff,Dr. NurlizaAbdullah,Dr.MuhamadMuhsinAhmadZahari,Dr.Tuti IryaniMohd.Daud,Dr.NorharlinaBahar,Dr.UmaVisvalingam,, LeeBoonHock

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iii October2008 NationalSuicideRegistryMalaysia Publishedby: SuicideRegistryUnit c/oDepartmentofPsychiatryandMentalHealth HospitalKualaLumpur 50586KualaLumpur Email:registry@nsrm.gov.my Website:www.nsrm.gov.my Thisreportiscopyrighted.ItmaybefreelyreproducedwithoutthepermissionoftheNational SuicideRegistryMalaysia(NSRM).Acknowledgementwouldbeappreciated.

ATTENTION
Thesedataisonlyforasixmonthperiod,notafullcalendaryear, andthereforeshouldbeusedadvisedly. The data represent absolute numbers and not rates and hence cautionisadvisedbeforedrawingconclusionsfromthem. In case of doubts, readers are advised to seek clarification from the Editors of this report. Written permission (addresses as above) should be obtained before quoting these data in any publicationorpresentation.
Suggestedcitationis:HayatiAN,AbdullahAA(Eds).NationalSuicideRegistryMalaysia: PreliminaryReportJulyDec2007.KualaLumpur2008.

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iv

ACKNOWLEDGEMENTS
TheNationalSuicideRegistryMalaysiawouldliketothankthefollowing: ForensicPhysiciansandstaffmembersoftheforensicdepartmentsandunitsoftherespective hospitalsfortheircontributionandcontinuedparticipation PsychiatristsandstaffmembersofthePsychiatricandMentalHealthDepartmentsfortheir participation StaffsoftheClinicalResearchCentre,inparticularDr.JamaiyahHanifandMr.WilsonLowfor thetechnicalinputinorganisingthisregistryandMs.Nuriniforthestatisticalanalysis TheInstituteofHealthBehaviourResearch,inparticularitsDirectorMs.SitiSaadiahHassan NudinandherassistantMs.KalaiVaaniyBalakrishnan Andallwhohaveinonewayoranothersupportedand/orcontributedtothesuccessofthe NSRMandthisreport DatoHj.Dr.AbdulAzizAbdullah/Dr.MohamadShahMahmood Chairman/ViceChairman NationalSuicideRegistryMalaysia

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LISTOFCONTRIBUTORS
CHAIRMAN (20 May 2008 onwards) CHAIRMAN (until 20 May 2008) EDITORIAL BOARD Dr. Nor Hayati Bt Ali Dr. Mohamad Shah Mahmood Pn. Siti Saadiah Hassan Nudin Dr. Norharlina bt Bahar Dato Dr. Bhupinder Singh Dato Dr. Suarn Singh Prof. Dr. Maniam Thambu Dr. Zahari bin Noor Dr. Jamaiyah bt. Haniff Dr. Nurliza Abdullah Dr. Salina Abdul Aziz Dr. Muhamad Muhsin Ahmad Zahari Dr. Uma Viswalingam Dr. Tuti Iryani Mohd. Daud Mr. Lee Boon Hock SITE PRINCIPAL INVESTIGATORS Dr. Mohd Suhani Mohd Noor Dato Dr. Bhupinder Singh Dr. Shafie Othman Dr. Nurliza Abdullah Dr. Khairul Azman Ibrahim Dr. Sharifah Safoorah Al Aidrus Dr. Mohamad Azaini Ibrahim Dr. Mohd Aznool Haidy Ahsorori Dr. Zahari bin Noor Dr. Wan Mohd Zamri Wan Nawawi Dr. Nurliza Ibrahim Dr. Jessie Hiu Perlis, Kedah Penang Perak W. Persekutuan Selangor N. Sembilan Melaka Johore Kuantan, Terengganu Kelantan Sarawak Sabah HKj IFPN IHBR HKL Penang Perak HUKM Kuantan CRC IFPN HKL UMMC HPj HUKM HKL Dr. Mohd Shah Mahmood Dato Dr. Haji Abdul Aziz bin Abdullah HKL

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vi SITERESEARCHCOORDINATORS
Tuan Hasli Tuan Ibrahim Hj. Noina Mohd bin Mohd Kassim Abdul Rahman bin Ibrahim Abdul Rani bin Hassan Mohd Nazri bin Mahmud Raja Mangeet Singh Basant Singh Muhammad Redzuan Aziz Faizul bin Samsudin Suhailey Mohd Noor Abd Hamid bin Muhd Nor Abdul Razak Darus Yusmadi Yunus Salina Hisham Khairin Anwar Azudin Mohajazaini Mohamad Baharin Mat Ail Azhar bin Junus Sapiee Ahmad Jibe a/k Lakipo Mohamad Hafeez Ibrahim Francis bin Paulus Perlis Kedah Kedah Penang Penang Perak Selangor Selangor Kuala Lumpur N. Sembilan Melaka Johore Johore Pahang Pahang Terengganu Kelantan Sarawak Sarawak Sabah Sabah

SECRETARIAT Mohd Kamarul Hafiz Abdul Khadir Ms. Suhailey Mohd. Noor Ms. Kalai Vaniy Balakrishnan Ms. Nurini Fazilawati Shaharuddin SRU IFPN IHBR CRC

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vii NSRMTECHNICALCOMMITTEEMEMBERS
CHAIRMAN (20 May 2008 onwards) CHAIRMAN (Jan 2007- 20 May 2008) Principal Investigator Co-Principal Investigator Asst Principal Investigator Co-Investigators Dr. Mohd Shah Mahmood Dato Dr. Haji Abdul Aziz bin Abdullah Dr. Nor Hayati Bt Ali Pn. Siti Saadiah Hassan Nudin Dr. Norharlina bt Bahar Dato Dr. Bhupinder Singh Dato Dr. Suarn Singh Dr. Zahari bin Noor Dr. Nurul Kharmila bt Abdullah Dr. Shafie Othman Technical Committee Dr. Sarfraz Manzoor Hussain Dr. Salina Abdul Aziz Dr. Mohd. Faizal Salikin Dr. Jamaiyah bt. Haniff Advisory Committee Director of Medical Development Division, Ministry of Health Malaysia Director of Disease Control Department, Ministry of Health Malaysia Director, Clinical Research Centre Prof. Maniam Thambu, HUKM ACP Suguram Bibi, Royal Malaysian Police Head of Emergency Services, Ministry of Health Malaysia SECRETARIAT Mohd Kamarul Hafiz Abdul Khadir, Suicide Registry Unit Ms. Suhailey Mohd. Noor Ms. Kalai Vaaniy Balakrishnan, Inst Penyelidikan Tingkahlaku Kesihatan

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viii

LISTOFCONTENTS
ACKNOWLEDGEMENTS........................................................................................................................IV LISTOFCONTRIBUTORS........................................................................................................................V LISTOFCONTENTS.............................................................................................................................VIII INTRODUCTION:....................................................................................................................................1 ABOUTTHENSRM.......................................................................................................................................1 Objective:............................................................................................................................................1 Inclusioncriteria:DefiningSuicide.......................................................................................................1 Instrument:..........................................................................................................................................2 DataFlowProcess:..............................................................................................................................2 Progress ..............................................................................................................................................3 . 1.DISTRIBUTIONOFCASESACCORDINGTOSTATES ...............................................................................4 . 2. DEMOGRAPHICS............................................................................................................................5 2.1 GENDERDISTRIBUTION.....................................................................................................................5 2.2 AGEDISTRIBUTION...........................................................................................................................5 2.3 ETHNICGROUPOFMALAYSIANCITIZENS...............................................................................................6 2.4 CITIZENSHIP....................................................................................................................................6 2.5 MARITALSTATUS.............................................................................................................................7 2.6 EDUCATIONLEVEL............................................................................................................................7 2.7 EMPLOYMENTSTATUS(N=86) ...........................................................................................................8 . 2.7.1 SpecificEmployment...............................................................................................................8 3. CHARACTERISTICSOFTHESUICIDALACT........................................................................................9 3.1 PRESENTATIONTOTHEHOSPITAL........................................................................................................9 3.2 PLACEOFSUICIDEACT.......................................................................................................................9 3.4 CHOICEOFMETHODS......................................................................................................................10 3.4.1 Methodvs.Ethnicity.............................................................................................................11 3.5 EXPRESSIONOFINTENTSPECIFYMODE.............................................................................................11 4. RISKFACTORSFORSUICIDE..........................................................................................................12 4.1 HISTORYOFPREVIOUSSUICIDEATTEMPTS..........................................................................................12 4.2 HISTORYOFSUBSTANCEABUSE.........................................................................................................13 4.2.1 TypesofSubstancesUsed:....................................................................................................13 4.3 PHYSICALILLNESSHISTORYANDTYPEOFILLNESS ................................................................................14 . 4.4 MENTALILLNESS...........................................................................................................................14 4.4.1 HistoryofMentalIllness.......................................................................................................14 4.5 LIFEEVENTSPRIORTOSUICIDE..........................................................................................................15 DISCUSSIONANDLIMITATIONS..............................................................................................................16 CONCLUSION.........................................................................................................................................17 REFERENCES..........................................................................................................................................18

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INTRODUCTION:
AbouttheNSRM
Until recently, Malaysia does not have official suicide rates. The National Statistics Department quoted figures as low as 1 per 100,000 suicides per year(Department of Statistics Malaysia2003);whilecrosssectionalresearchindifferentpartsofthecountrysuggestedhigher figures(Maniam1988;Hayati,Salinaetal.2004).Itispostulatedthatamongthedifficultiesthat hadcausedthesediscrepanciesare:thedegreeofsubjectivityinidentifyingadeathofsuicide, lack of structured data describing the manner of death for cases of traumatic or nonnatural deaths,andinconsistenciesinthewaytermsaredefinedanddatacollectedandcoded. Inresponsetothis,theNationalSuicideRegistryMalaysiawasofficiatedin2007tocompile the census of suicidal deaths that occur in Malaysia via its network of forensic services. It is sponsoredbythePsychiatricandMentalHealthServicesandtheForensicMedicineServicesof the Ministry of Health Malaysia (MOH); while the Clinical Research Centre (CRC) provides the technicalexpertise.In 2008, theInstitute ofHealth BehaviourResearchhas come on boardto createaplatformforfurtherresearchtobecarriedoutinthisarea.TheNSRMismanagedbya JointTechnicalCommitteecomprisingofthefouragencies.Meanwhile,anAdvisoryCommittee provides governance to ensure that the NSRM stay focused on its objectives and to assure its continuingrelevanceandjustification. Objective: The National Suicide Registry Malaysia (NSRM) aims to create a nationwide system to capturedataoncompletedsuicideinMalaysiai.e.therates,methods,geographicandtemporal trends and the population at high risk of suicide. Data from this project will provide more detailedstatisticsonsuicideinMalaysia.Thisisimportantforhealthprioritizingandidentifying ofareaswhichhealthprovidersshouldfocuson. Inclusioncriteria:DefiningSuicide Indefiningsuicide,theWorldReportonViolenceandHealthquotedawellknowndefinition by Encyclopaedia Britannica (1973) and quoted by Shneidman, i.e.: the human act of self inflicting onesown life cessation(WorldHealthOrganization 2002). Itisobviousthatin any definitionofsuicide,theintentiontodieisakeyelement.However,unlessthedeceasedhave made clear statements before their death about their intentions or left a suicide note, it is extremelydifficulttoreconstructthethoughtsofpeoplewhocommittedsuicide.Tocomplicate matters, not all those who survive a suicidal act intended to live, nor are all suicidal deaths planned. It can be problematic to make a correlation between intent and outcome. In many legalsystems,adeathiscertifiedassuicideifthecircumstancesareconsistentwithsuicideand ifmurder,accidentaldeathandnaturalcausescanallberuledout.Thus,therehasbeenalotof disagreementaboutthemostsuitableterminologytodescribesuicidalbehaviour. The World Report on Violence and Health had commended the proposal to use the outcomebased term fatal suicidal behaviour for suicidal acts that result in death and

2 similarlynonfatalsuicidalbehaviour1forsuicidalactionsthatdonotresultindeath(6).The NSRMhadadaptedthisstanceandareregisteringcaseswhichareclassifiedasfatalintentional selfharm. These codesare coveredin ChapterXXof ICD102i.e.External Causesof Mortality and Morbidity (X60X84) (World Health Organization 2007). The diagnosis will be based on a postmortem examination of the dead body and other supporting evidence that shows a preponderanceofevidenceindicatingtheintentiontodie. Instrument: Data is collected via a structured Case Report Forms (CRF). The technical committee had reviewedtheliteratureandcollectedtheviewsofprospectiveparticipantsbeforedetermining thefinaldesignoftheCRF.Thecommitteehadalsopreparedaninstructionmanual(hardand soft copies) alongside the CRF to ensure systematic and efficient data collection. With due regard to the sensitive nature of data acquisition (Reiget 2001), a specific chapter had been dedicated to the techniques of interviewing the grieving family members. Regional and nationallevel training has also been carried out to enhance the competence and capability of officersinvolvedinthisproject,aslistedbelow: State/Zone Perak Central North Date 6April2007 14Mei2007 7Jun2007 Venue No.Hospitals No.of represented Participants 16 35 17 36 15 36

HospitalBahagia,UluKinta HospitalSerdang HospitalSultanahBahiyah,Alor Star South 11Jun2007 HospitalSultanahAminah,Johor 11 25 Bahru EastCoast 14Jun2007 HospitalKuantan 22 51 Sabah 18Jun2007 HospitalQueenElizabeth 16 30 Sarawak 19Jun2007 HospitalUmumSarawak 17 29 Trainingsessionsincluderecognitionofcases,developingstandardoperatingproceduresto capturethedata,interviewtechniquesandpracticalsessionsinfillingouttheCRF.Despiteour best efforts, there has been some limitations in the outreach of training sessions, and will be discussed further at the end of the report. For more detailed information on the variables, pleasevisitourwebsiteatwww.nsrm.gov.my DataFlowProcess: Theregistrywillbecoordinatedatthecentraldatamanagementuniti.e.theSuicideRegistry Unit(SRU).Atthestatelevel,thereisaseparatedatacollectioneffortcoordinatedbytheState Forensic Pathologists office. The officer in charge for each state is known as the State Coordinator.TheStateCoordinatorwillidentifystaffsfromtheforensicunitofotherhospitals in their state to handle data collection at the district level. All hospitals that carry out data collectionwillbecategorizedasaSourceDataProducer(SDP).

Suchactionsarealsooftencalledattemptedsuicide(intheUnitedStatesofAmerica),parasuicide anddeliberateselfharm(termswhicharecommoninEurope) 2 TheInternationalStatisticalClassificationofDiseasesandRelatedHealthProblemsversion10

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3 TheSDPsshalldevelopanalertsystemtoidentifycases.Datawascollectedviainterviews with the family members, significant others or police; and review of medical records or other officialdocuments.TherelevantvariableswererecordedinthepaperbasedCRF. The Registry Manager based in the SRU will track data returns and prompt State Coordinators to submit data whenever they fall behind schedule in reporting data. Data protection procedure had been put in place, following standard disease registration practice, andincompliancewithapplicableregulatoryguidelines. Progress Data collection had begun manually in July 2007. There had been some problems due to lossofformsinthemailanddelayresultingfromlateverificationofcases.Inviewofthat,an onlineregistrationsystemhadbeendevelopedbeginningOctober2007.Datacollectionin2007 is also limited to hospitals under the purview of the Ministry of Health. However, in 2008, efforts have been made to invite forensic departments in university hospitals to participate in thisregistry. Datawillbereportedincollapsedfiguresortrends,andwillnotgivedetailsoftheindividual. RealtimebriefreportswillbeavailableforthestateforensicphysiciansviatheNSRMsofficial website www.nsrm.gov.my, while more detailed queries will have to go through the advisory committee. Meanwhile, annual reports will be produced to give a clearer picture of national trends.

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1.DistributionofCasesAccordingtoStates
The population of Malaysia in 2007 is estimated to be 27.17 million. Selangor has the highestpopulation,i.e.4.96million(18.3%)followedbyJohore3.24million(11.9%)andSabah 3.06 million (11.3%). States with less than one million population are Negri Sembilan (0.98 million),Malacca(0.74million),Perlis(0.23million)andFederalTerritoryLabuan(0.09million). Theprevalenceofsuicideisreportedassuicideratesperyearofagivenpopulation.The suicide rate per year is the number of residents suicidal deaths recorded during the calendar year divided by the resident population (Centers for Disease Control and Prevention 2003), as reportedintheofficialMalaysianNationalStatisticsDepartmentcensusfigures,andmultiplied by 100,000 (Centers for Disease Control and Prevention 2003). As mentioned earlier, data collection in 2007 can only be started in July thus data was available for 6 months only and couldnotbeusedtogeneratesuiciderates. Notwithstanding that, the number of cases registered during this period was 113 which mayseemratherlow.Thismaybeduetothefactthateventswithindeterminateintentwere notcapturedinthisregistry(adheringtotheinclusioncriteriawhichrequiredevidenceshowing apreponderanceofevidenceforintentiontodie).

DistributionofCasesAccordingtoState
25 noofsuicidecases 20 15 10 5 0 Penang
Figure1:Distributionofsuicidecasesaccordingtostates

21

22 19 16 11 13

5 1 Perak Selangor WPKL Johor Pahang T'ganu

Sabah Sarawak

Figure 1 shows the distribution of cases according to states. Data is not available for five statesi.e.Perlis,Kedah,NegriSembilan,MalaccaandKelantan.Itneedstobeemphasisedhere thattheNSRMwasofficiatedinearly2007,andthisdatacollectionisaveryearlyattempt.Most oftheproblemsindatacollectionwererelatedtomanpower,forexample: There were no designated paramedical staffs to handle the Forensics Unit in the district hospitals;theywereusuallyborrowedfromtheEmergencyDepartment. NonavailabilityofForensicPhysiciansincertainstatestocoordinatetheSDPswhichisthe caseinallfivestateswhichdidnotsubmitanydata.Apartfromprovidingleadership,the forensicphysiciansalsoneedtoverifytheformsmanuallybeforetheywerereturnedtoSRU Rapid staff turnover some of those already trained had been promoted and transferred elsewhere

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5 herehadalso obeenlogisticsproblems,forexample e:SDPsdidn notreceiveth heCaseRepo ort Th Forms s(CRFs)whic chweresentbytheSuicideRegistryUn nit(SRU)viam mailthiswa asespeciallys so in Eas Malaysia; u st usage of non nofficial form mats instead o the CRF to register cas and loss of of o ses comp pletedCRFsin nthemail.O Otherproblem mswerethe lackofinform mantsandlac ckofintervie ew areaw whichhampe eredtheinterviewprocess. Th developm he ment of an online regist o tration will h hopefully address some of the abov ve proble ems.Itwillp providemore econvenienceforForensicPhysicians toverifycase esevenifthe ey areoutstation.Th hesystemcanalsoautog generatesom mebasicdata andthesew willbeavailab ble realtime; can be used to diss seminate info ormation and other teaching materia to the SDP d al Ps. Howe ever,theinter rnetcapabilit tiesvariedwidelyamongt thedifferenth hospitals,and dtheremayb be anecessitytoprov videmobileb broadbandca apabilitytoth herespective estatesduetothefrequen nt move ementofthef forensicphys sicians.

2. DEMO OGRAPH HICS

2.1 Gender Distributi ion

Genderd G distribut tion

Fem male; 27%;(n=31)

Ma ale;73%;(n=82 2)
Figure2:GenderDistr ributionofsuicid decases(n=113)

Thegenderdistributionasshow wninFigure2 2showsapre eponderanceofmales,withamaleto leratioofapp proximately3 3:1.Thisisco onsistentwith hinternationa alliterature. femal

2.2

Agedist tribution

Figure3:Agedistribut tionofsuicideca ases

Th heagedistrib butionisassh howninfigure e3.Dataiso obtainedfor1 111cases,wit ththemeano of 38.24 4years;media anof35years;andthemo odeof30yea ars(multiplem modesexist).Theyounge est casew was12yearsofageandth heoldestwas s93years.

2.3

Ethnicgrou E upofMala aysiancitiz zens

Others;9%;(n=10) O Indigen nousgroups fromEa astMalaysia; 8% %;(n=9)

E Ethnicity y
Mala ay;11%;(n=12) )

Indian;29%;(n=31) Chi inese;43%;(n= =47)

Figure4:Distributionofeth hnicityamongsuicidevictims

Them midyearpopu ulationfor20 007showedt thatMalaysa andotherBu umiputeragro oupsmade up 66.4%ofthepopu ulation, Chine 24.9%,Indians 7.5%and others 1.3 All states ese 3%. sgenerally t end, i.e. bum miputera being the bigge group ex est xcept for Penang with showed the same tre bumipute eraandChinesealmostatpari.e.44.2p percentand44.8respectively. In con ntrast, the fig gures collecte by NSRM reported 11% for Malays 43% for Ch ed s, hinese and 27% for Indians. This indicated an overrepre s esentation of the Indians, which had been seen , repeatedl lyinearlierst tudies.

2.4

Citizenship C p

Most ofthesuicidevictimswereMalaysian ns(87%,n=95 5),whileforeignerscontributed13% (n=14) of suicides in Malaysia. Among these the highe percentag was contr f e, est ge ributed by Indonesia ans(43%,n=6 6)followedby ytheNepales se(22%,n=3)asshowninFigure5.
rean;7%; Singapor (n= =1) Filipi ino;7%;(n=1) Nepales se;22%; (n=3) Myan nmarese;7%; (n=1)
Figure5:Co ountryoforiginfornonMalaysiansuicides

Chines se;7%;(n=1) Indian;7 7%;(n=1)

Indonesian;43%; =6) (n=

In gen neral,thesoc ciodemograp phic profileof fsuicide victi ims was similar to previous studies. According to World H g Health Organi ization, the s suicide rates worldwide fo the year 2007 were or 2 consistently higher am mong males compared to females(World Health Or c rganization 2 2008). The age group was also consistent wi pervious studies, whe the pred p c ith ere dominant age group to e commitsuicidewerea amongtheyo oung(McClure2000).The eethnicdistr ributionwere esimilarto ngs er i, the findin form othe local studies(Nadesan 1999; Hayati Salina et al. 2004; Teo, Teh et al. 2008)wh hereIndiansw wereconsiste entlyreportedtohavethe ehighestsuiciderate.

2.5

Marital status
owed; Wido 1%;(n n=1.2) Married d; 51%;(n=5 50)

Single;47% %;(n=47)

Cohabiting; n=1) 1%;(n

Figure4:Distributiono ofmaritalstatusofsuicidevictims

Co ontrarytointernationalli iterature,wh heresuicideis susuallycom mmittedbypeoplewhoare single e(WorldHealthOrganizat tion2002),th hedatashowedthatasignificantnumberofmarrie ed perso onsalsocomm mittedsuicide e(51%,n=50) ).
Table1 1:Gendercomp parisoninassociationwithmaritalstatus

Missing Total Data (gender) Male 41(50%) 31(37.8%) 5 5(6.1%) 0 5(6.1%) 82 Female 9( (29%) 16 6(51%) 4 4(12.9%) 1(3.2%) 1(3.2%) 31 Total 50 47 9 1 6 113 Whenanalysedgenderwis W se,aninterestingdifferenc ceemergesb betweenthe sexes.Marrie ed males contributed 50% (n=41) of suicidal deaths w s d while singles contributed 38% (n=31 d 1). Mean nwhile for fem males, a muc higher pro ch oportion were singles (51. e .6%, n=16) as compared t s to those ewhoaremarried(29%,n=9),asshowninTable2. However,th hisassociation nisstatistical lly not significant (p> >than 0.05). This trend n needs to be observed on a longer ter before an rm ny conclu usions can be made about the association betwe gender and marital status among een gst those ewhocommit ttedsuicidein nMalaysia.

Ma arried

Single S

W Widowed

Cohabiting C

2.6

Educationlevel

EducationLe evel
Tertiary;3%;(n n=3) Non ne;8%;(n=9) Primary; 12%;(n=14) Secondary y; 34%;(n=38 8)

Figure5:Educationlev velofsuicidevic ctims

Th education level was not known for 43% (n=49) of cases. F those wh he n For hose educatio on level was known, the majority had studied until secon y d ndary level. T This is inkee eping with th he nation naltrends,wheretheaver rageyearsofschoolingisa about6.8yea arsorlowers secondarylev vel (UNES SCO2008).

2.7

Employmentstatus( E (n=86)

Employm E mentSta atus

2%;(n=2) Disabled;2 Unemploy yed;27%; (n=2 23) Retired;2%;(n n=2) Temporary; ;5%; (n=4) Parttim me;4%;(n=3)
Figure6:Em mploymentstatu usofsuicidevictims

Housewife;3% %; (n=3)

Fulltime;57%; ; (n=49)

Them majorityofsuicidevictims (57%)weref fulltimeempl loyed,while2 27%wereunemployed. Theremainderweree eitherparttim me(4%)orte emporarily(5 5%)employe ed,2%werer retired,2% wererece eivingdisabilit typensionwhile3%werehousewives. 2.7.1 Sp pecificEmployment Specif employme was iden fic ent ntified in 46 cases. The most common employm ments were students( (n=9;20%),3 3businessmen n(n=3,7%),d drivers(n=3,7%),labourer r(n=3,7%)an ndsecurity guard(n=4,9%).Theo otheremploy ymentsareas slistedbelow w.
10 9 8 7 6 5 4 3 2 1 0

Figure7:Sp pecificemploymentofsuicidevictims

Ofthe e9students,6werefema alesand3we eremales.Only1wasMa alay,aged22,whilethe otherswe ere5Indians,2Ibanand1 1Murutaged12to17yea ars.Schoolpr roblemswere ecitedin2 cases,inti imatepartnerproblemsin nanother2w whilenolifeev ventwasiden ntifiedin5ca ases.

3. Chara acteristi icsofth heSuici idalAct t

3.1

Dieda atWard;11%; (n=13) DiedatER R;1%;(n= 1) 1 BID;88%;(n=99) B

Present tationtoth heHospita al

rom113case esofsuicide, 88%ofthec caseswereB BroughtinDe ead(BID)by ythepolicefo or Fr postm mortem exam mination, 11 of cases died in the ward and 1 died in the emergenc 1% 1% cy depar rtment.Those ewhodiedinthewarda andemergencydepartmentindicateth hattheperso on who committed suicide did not die im mmediately but went t through the resuscitatio on stage/ /process.Mo ostofthecase eswhichwere eadmittedto othewardha adusedpoiso oningmethod ds. Theydonotdieim mmediatelyan ndweresenttothehospit talbytheirne extofkin.

3.2

Placeof fsuicideac ct
Frequency 7 73 1 10 5 5 3 2 2 1 1 3 8 113 Per rcent 64 4.6 8.8 8 4.4 4 4.4 4 2.7 2 1.8 1 1.8 1 .9 .9 2.7 2 7.1 7 10 00.0

Table2 2:Placewheret thedeceasedcarriedoutthesu uicidalact Placeo ofSuicideAct OwnHome(IncludingGirlfriendsHom me[1],Neighbou ur[1]) ResidentialInstitution Farm/Plantation Comme ercialBuildings/ /TradeServiceA Areas Industr rialArea Street/ /Highway School PoliceC Custody Gravey yard Unspec cifiedPlace Missin ngData Total

A large majority of patients (64.6%, n= =73) chose t commit su to uicide at hom settings, a me as shown in Table 3. Residential institution is the next co s ommonest pla with a to of 8.8% o ace otal of cases. Another 4.4 of suicidal acts took place at farm or plantat 4% tion areas an commerci nd ial buildings or trade service area Other loc as. cations were industrial ar rea, school, police custod p dy, graveyard and stre eet/highway. The most l . likely reason why people tend to com mmit suicide at theirownhomesisprobablydu uetotheeas seofaccessandensuringp privacy.Itwouldbeshow wn in the next section that the co e n ommonest lif event prec fe cipitating suic cide is an int timate partne er proble emmaking gthe

10

3.4

Choiceofmethods
0 10 20 30 40 50

X61Antiepileptics,sedativehypnotics, 01 X67Gases&othervapours X68Pesticides X69Unspecifiedchemicals&other 0 2 X70Hanging,strangulation,suffocation X71Drowning X73Rifle,shotgunotherlargerfirearm X76Smoke,fire,flames X78Sharpobjects X80Jumpingfromhighplace X81Jump/lyingbeforemovingobject 0 2 1 2 2 0 3 2 1 0 6 10 11 47 Male Female 0 5 7 11

Figure8:Gendercomparisonforchoiceofmethodsofsuicide(N=113;males82;females31)

Methods of suicides for this study are according to the ICD10 classification. This study showedthatthemostfavouredsuicidemethodsamongstMalaysianarehanging,strangulation andsuffocation(X70).Bothmaleand female favouredthismethodforsuicide.Asshownin a study by J.P Henderson et al(Henderson, Mellin et al. 2005), the majority of suicides were by hanging. Technically, it may also be the easiest method to be diagnosed. The second most widely chosen method is exposure to pesticide (X68), followed by jumping from height (X80) whichcontributed14.16%ofthesuicidecases. Itisinterestingtonotethatthefemalevictimsinthisgroupofpatientshadchosenaslethal methodsasthemales.Theaccessibilityofthemethodmayhavecontributedtothepreference. However,thistrendshouldbeobservedinthecomingyears. The other suicides method found in the study were exposure to gases and other vapours (X67), smoke, fire, flames (X76), drowning (X71), exposure to unspecified chemicals & other noxious substance (X69), jumping or lying before a moving object (X81), sharp objects (X78), rifle, shotgunor otherlarger firearm (X73)and exposure to antiepileptics,sedative,hypnotics, psychotropics(X61).

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11 3.4.1 Methodvs.Ethnicity
0 X61Antiepilepticsetc X67Gases X68Pesticides X69Unspecifiedchemicals X70Hanging,strangulation X71Drowning X76Fire,flames X80Jumpfrheight X81Movingobjects
0 0 0 1 1 2 9 3 0 1 17 25 0 1 1 3 4 9

10

15

20

25

30

Malay Chinese Indians

Figure9:Ethniccomparisonformethodsofsuicide

From table 3.4.1, the commonest method of suicide for all the major ethnic groups were Chinese,IndiansandMalayswashanging.Thisisprobablyduetotheaccessibilityandefficiency of this method. The second most common method chosen by the Chinese and Malays was jumpingfromheight,whileIndianstendtousepesticidepoisoning.

3.5

Expressionofintentspecifymode

Among the 113 victims, only 20 (17.7%) had expressed the intent for suicide. The informants for 72 cases (63.7%) said that there was no indication of intent at all, while the remaining19%werereportedasunknown.Forthosepatientswhoindicatedtheir intent,the mostfrequentmodewasviaverbalexpression(n=13;11.5%)asshowninTable4.
Table3:Typesofexpressionofsuicidalintent Indication of Intent Verbal Expression Preparation Suicide Note (Including 1 SMS) Rehearsal None/ Unknown Total Frequency 13 3 3 1 93 113 Percent 11.5 2.7 2.7 .9 82.3 100.0

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12

4. R RiskFac ctorsfo orSuicid de

Examining suicide deaths ret e trospectively, 5 factors that appear to be most directly , r connected dtosuicideriskwerelistedincaserepo ortform.The eyare: 1. HistoryofPrev viousSuicideAttempts stanceAbuse e 2. HistoryofSubs 3. Physicalillness s 4. M MentalIllness 5. Li ifeEvent Many individuals s y sharethese r factorsw risk without conte emplating suicide.Because different e individual can unique experienc these risk factors, no s ls ely ce single riskscoring system has been m widely ac ccepted withi the menta health clini in al ical community. Risk factors for suici can be ide characteristicsofanin ndividual(beingmale,hav vingamenta alorphysical illness,havin ngafamily history of suicide), situational (livin alone, bei unemploy f ng ing yed) or behavioral (alcoho olism/drug abuse or owning a gun). Menta disorders (especially m g al mood disorde conduct disorders, ers, eabuse andd disruptivedis sorders),prev vioussuicideattempts,fa amilyhistory ofsuicidal substance behaviour r,andstressfullifeeventsareriskfacto orsofsuicideforbothgenders(Goulde etal.1996; Shafferet tal.1996;Gro oholtetal.19 997,1998;Brentetal.199 99;Beautrais,2000). Know wingthenumberofdeaths in anygivenagegroup allowsservic s ceproviderst toplanfor thelevelo ofsuiciderela atedservicesthatmaybeneeded,whileunderstand dingsuicided deathrates pinpointsthegroupsm mostatrisk.

4.1

HistoryofP H PreviousS SuicideAtt tempts

Becks stheorystate esthatprevio oussuicidalex xperiencesen nsitizessuicid derelatedtho oughtsand behaviour rssuchthatt theseideasb becomemore eaccessiblea andactive.Th hemoreacce essibleand active the schemas and modes become, the more easily they are tr ese e y riggered and the more severeare ethesubsequentsuicidal episodes(Te easdale,1988).Previousst tudieshavep proventhat multiples suicideattem mptsareama arkerforseve erepsychopa athologyand psychosocialproblems and hence is a strong predictor fo suicide. Ris of suicide increases 50 (Owens, 2002) to 100 or sk 0 (Hawton 1988)timesw withinthefir rst12months safteranepi isodeofselfharm,compa aredtothe generalpopulationrisk. Approxima atelyonehalf fofpersonsw whodiebysu uicidehavea ahistoryof selfharm(Foster,1997 7),andthisproportioninc creasestotwo othirdsinyoungeragegro oups.

sattempts UNKNOWN; Previous 18%;(n=20) YES;6%;(n=7)

NO;73%; ;(n=82)

Figure10:H Historyofprevio oussuicideattem mptsamongsui icidevictims

In con ntrast to find dings in previ ious studies, findings from our study show that m m most of the subjects did not have any history of previous suicidal attempt while only a small p d percentage (6.2%) rev vealed a pos sitive history of previous suicide attem This could be argue that the mpt. ed

13 1 y cide were un naware of the victims pa suicidal b e ast behaviours an nd family informants for the suic attem mptsasthesu ubjectsmayn nothavereve ealedthepast tsuicidalbeh haviours.Mor reover,there is highn numbersofse elfharmersw whodonotse eekmedicalattention.

4.2

History ofSubstan nceabuse e

Li ittle is known about the types of substance mos strongly re st elated to suic cide attempt ts. Suicid attempts could be ass de sociated with a past history of substance disorde or could b h er be associatedwithha avinganactiv vedisordero only.Substanc ceuserswith hsuicidalidea ationshavea an elevat risk of f ted first suicide attempts eve in the ab a en bsence of a p plan. It is kn nown that th he presenceofaplan nistypicallyu usedasakey yindicatorof fsuiciderisk amongideatorsbutlittle is known about the predictors of attempted suicide amo ideators without a plan. A possib o ong ble explanationofunp plannedattem mptsamongi ideatorsisthatthedisinhi ibitionissomehowinvolve ed e e. ave hat an n he in the effects of substance use Studies ha shown th there is a association between th numb berofsubstan nceusedandtheonsetofsuicidalideat tion,inadose erelatedman nner.

Sub bstanceA Abuse

Missing;3%; Unknown;17%;(n=4) ) (n=19) Yes;26 6%;(n=29)

No;54%;(n=61)
Figure11:Historyofsubstanceabuse eamongsuicidevictims

Ourfindingrevealthatma O ajorityofthe suicidesdid notgiveapo ositivehistoryofsubstanc ce abuse e.Hereagain, ,familyinform mantsmaynotbeinforme edaboutsuchhighriskbe ehaviourinth he subjec cts.Itcoulda alsobepossib blethatfamilyinformants scouldunder restimatethe emagnitude of substa anceuseinthesubjects.T Thisalsocouldbeexplain nedbythefac ctthatsome subjectscould havebeenlivingaw wayfromthe eirfamilies. Substances Used: 4.2.1 TypesofS

Typeo ofSubsta ALCOH ance HOL;33%;

(n n=9) TOBACCO;52%; (n=14) HEROIN,MORPHIN; 7% %;(n=2) MA ARIJUANA;4%; (n=1)

STIMUL LANTS; 4%;(n n=1)

Figure12:Typesofsub bstancesusedb bysuicidevictim ms

14 Fromthedataobtained,itwasfoundthatmajorityofthevictimsgaveapositivehistoryof tobaccouse.Incontrasttothecurrentfindings,previousinternationalstudieshavefoundthat comorbid alcohol dependence or misuse has been associated with higher incidence of suicide (Fawcettetal,1990;Dugganetal,1991;Bronisch&Hecht,1992). Thepossibleexplanationforourfindingsisthatthereisahigherprevalenceoftobaccouse ratherthanalcoholuseinthiscountry.Moreover,alcoholabusecouldbeoverlookedinwomen whichwouldresultinlossofvitalinformation.

4.3

Physicalillnesshistoryandtypeofillness

Psychological autopsies have found that having a general medical disorder is a strong predictorofcompletedsuicide.Possibilitiesarethatpersonswithphysicalillnessaremorelikely to be depressed and depressed individuals are more likely to be suicidal. Therefore, the depression could fully explain the association between physical illness by a general medical conditionandsuicide.Alternatively,medicalillnessescouldrepresentanindependentriskfactor for suicidality over depressive symptoms. Hence, it is vital to to understand whether such relationshipexistsaftercontrollingfordepressiveillness.Havingmorethanonemedicalillness, conferredaparticularhighrisk(Druss,2000) Thepresenceofaphysicalillnessmayrepresentproxiesforotherintermediatefactorssuch asfunctionaldisability,disruptionofsocialsupport,chronicpainetcwhichmayleadtoalower qualityoflife.Thusindividualmayregardtheirlifeasnolongerworthliving. Sevencases(6.2%)werereportedtobehavingaphysicalillness.Subjectsgaveahistoryof medical illness such as diabetes (n=2) and cerebrovascular accidents (n=2). One subject respectively had history of coronary arterial disease, malarial infection and abdominal discomfort. Previous studies have shown that general medical conditions such as multiple sclerosis, cancer and conditions which have potentially lifethreatening exacerbations like asthmaandpulmonarydisease,havebeenimplicatedasriskfactorsinsuicide.Biascouldoccur in obtaining information where the family informants for the suicides may have over emphasisedpossiblecausalfactorsinanattempttoexplainthedeath.

4.4

MentalIllness

4.4.1 HistoryofMentalIllness The presence of mental illness has been identified as a strong predictor of suicide completions. Three major mental disorders with high risk for suicide are Major Depressive Episode, Dependent use of substances and emotionally unstable Personality Disorder(Cheng, Chenetal.2000).Peoplewithmorethanoneofthesediagnosesareatparticularlyhighrisk,and the possibility of suicide is also greater depending on the severity of the disorder. However, interviewswithnextofkinaftersuicidedeathsinNSRMhaverevealedthat77%(n=77)ofall suicideshavenohistoryofmentalillnessandonly7.1%(n=8)havehistoryofmentalillness. Amongthedeceasedwhohadhistoryofmentalillness,2(1.8%)ofthemwerediagnosedto haveDepression,2(1.8%)hadSchizophreniaand3(2.7%)wereundiagnosedanduntreated.

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15 Intermofpreviousadmissiontoapsychiatricfacility,only2ofthedeceasedwerereported to be positive. One case had been admitted to Hospital Bahagia Ulu Kinta and Hospital Ipoh respectively.ThisreflectsthenumberofpatientswhowerediagnosedtohaveSchizophrenia. Themajorityofthedeceased(n=79,69.9%)havenofamilyhistoryofmentalillness.Only2 ofthem(1.8%)havepositivefamilyhistoryofmentalillness,while28.3%(n=32)werereported asunknown.

4.5

LifeeventsPriortoSuicide
0 IntimatePartnerProblem FinancialProblem Medicolegal JobProblem SchoolProblem DeathofLovedOne Hallucination PersonalProblems UnderSOCSO 5 10 15 20 25

Figure13:Typesoflifeeventsexperiencedbysuicidevictims

A high proportion of suicides (n = 38, 33.6%) had experienced life events within three months before suicide. Among this group, 60% (n = 23) of the deceased had intimate partner problemand13%(n=5)hadfinancialproblem.Twosubjectsrespectively(5%)werefoundto havejobandmedicolegalproblemspriortosuicide.Interestingly,36%ofthedeceasedhadno lifeeventthreemonthspriortosuicideand36%ofthemwerenotknownwhetherlifeevents precipitatedtheirsuicide. Most of previous studies investigating the relationships between recent life events and suicidehavehadsmallsamplesizeandhavefocusedonpsychiatricpatients(Heikkinen,Aroet al.1993)(Heikkinenetal,1994),whichmakesitdifficulttoexaminethepowerofanassociation. Afewmorerepresentativestudies(Bunch1972;Foster,Gillespieetal.1999)examinedsuicides from general populations. These studies have generally found that recent life events play an important role in precipitating suicide. It was found that only loss events have a significant contributiontotheriskofsuicide. Commonfactorsthatappeartoprecipitatesuicideamongyouthincludeavarietyofstressful lifeeventssuchasdisciplinarycrises,interpersonalloss,interpersonalconflict,humiliationand shame.Suicidalyoutharealsomorelikelytobedepressed,abusealcoholandhaveahistoryof aggressiveandantisocialbehaviour.

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16

DISCUSSIONANDLIMITATIONS
Severallimitationshadbeenidentifiedinthisproject.Indefiningsuicide,forexample,the requirementforintentiontodiemayhaverestrictedthenumberofcasesregistered.Thismay beaddressedeitherby includingcodesY10Y34(EventofIndeterminateIntent)ofICD10into theNSRMorbydevelopingaViolentDeathReportingsystemwhichwouldcaptureallkindsof violentdeaths. Trainingwise, although efforts had been made to train all the officers managing the SDP centres,therehadbeensomecommunicationandlogisticsproblemsingettingthemtocome. Generally there is a tendency to associate suicide with psychiatry: resulting in hospital administratorssendingstaffsfromthepsychiatricdepartmentstothetrainingsessioninstead oftheforensicunitsasrequested.Alotoffollowingthroughneedstobedonetoenhancethe outreachoftrainingsessions. As mentioned earlier, human resource is a major problem and might not be remediable immediately.Themajorityofstaffsmanningtheforensicsunitsindistricthospitalsarealsoin chargeoftheEmergencyDepartment,Transportetc.Thismightdistractthemfromeffectively screen for cases and allocate time to interview the nextofkin. Since the shortage of paramedical staff is ubiquitous nowadays, the forensic fraternity might consider other alternativeslikehavingscientificofficerstoassistininformationgathering. Processwise,amajorchallengeiswhenpatientsdieduetocomplicationsofthesuicidalact afterbeingadmittedtotheward.Attimes,thestaffsintheforensicsunitarenotawareofthe history and had released the body before the trained officer had a chance to interview the familymembers.OneofthewaystocheckforthisisbyworkingcloselywiththeRoyalMalaysia Police and comparing the outcome of their sudden death report investigations with cases capturedbytheNSRM. The interview also poses some problems: the informant who came to collect the bodies sometimeshasnotmetthedeceasedforalengthyperiodpriortothelattersdeath.Thismay affecttheaccuracyofdata.Inthecaseofforeigners,fellowworkersoremployerswereusually unable to give any valuable information. For Malaysians, efforts should be made to carry out psychological autopsy studies to glean more information from relatives. Although there are differingviews,itwasgenerallyagreedthattheinterviewshouldbecarriedoutabout3months followingthedeath(PouliotandLeo2006).Infrastructurewise,someforensicunitsindistrict hospitalsareverysmallandhardlyhasanyspaceforinterviewingthegrievingfamilymembers. Notwithstanding the NSRM, providing better interviewing facilities in forensic units would certainlybenefittheclientsaswellasthestaffs.Itwillprovideamoreconducivesettingwhen staffs have to break bad news or carry out any form of information gathering with family members. There had been some difficulty in capturing the actual time of suicidal act, which was supposedtoberecordedinmilitaryhours.Ithadbeensuggestedthatinthefuture,widertime framesbeusede.g.midnightto6am,6amto12noon,12noonto6pm,6pmto12midnight. Atthemoment,theNSRMdoesnothavesufficientmanpowertocloselymonitorthequality ofdatacollection by SDPs.Mostofthesupervisioniscarried out by theforensic physicianor

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17 senior medical assistant. However, site visits have been planned so that some form of supervisionfromSRUandfeedbacksessionscanbecarriedoutmoreeffectively. Althoughtheonlineregistrationsystemisenvisionedtoimprovedatacollection,thiswillbe dependent on the availability of internet resources that is available in each hospital. We certainlyhopethatpolicymakerswouldconsiderdeveloping/upgradingITresourcesinforensic setupstoensurebetterdatacollection.

CONCLUSION
Suicide rates are a recognized health outcome indicator internationally (World Health Organization2001).Thisprojectwillprovideinformationonthenaturalhistoryandcausationof suicide;thecontributingfactorsmostamenabletopreventiveefforts;andthemostappropriate targetpopulation(s).Thisinformationwillaidinplanningandplacepreventiveeffortsonamore solid foundation (World Health Organization 2002). This registry will be able to provide both stateandnationalleveldata. Suicidalactswillcausemedicalcostswhichincludeemergencytransport,medical,hospital, rehabilitation,pharmaceutical,ancillary,andrelatedtreatmentcosts,aswellasfuneral/coroner expenses for fatalities and administrative costs (National Center for Injury Prevention and Control2002).Betterandevidencebasedeffortsatsuicidepreventionmaybeabletoreduce suicideratesinMalaysiaandallowthegovernment/familiestooffsetthesecosts.Apartfrom that, a structured investigation into the process of identification and reporting of nonnatural deaths (specifically suicide) will assist in streamlining the management of dead bodies and ascertainingthemannerofdeath.Indirectlyitwillalsoprovideatrainingexerciseformedical officersinreportingdeathsbysuicide. Although thisis anearly effort,certain interestingtrend hademerged,namely:thehigher proportion of married persons who committed suicide; male preponderance in those who are married as compared to females; the choice of lethal methods by the female suicides. We certainly hope that with better support, infrastructure and human resource training, these trendscanbeinvestigatedfurther. The uniqueness of NSRM lies in its multidisciplinary platform. Although this may present somecommunicationproblems,italsooffersadvantagesintheformofpoolingofresourcesand expertise.Afterall,suicideisaverycomplexphenomenon.Beingaregistry,theNSRMmight not be able to provide indepth details about the causation of suicide. However, it would certainlyidentifytrendsandformthebaselineforotherresearchinthisarea.

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18

REFERENCES
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19 20. UNESCO.(2008)."UnitedNationsHumanDevelopmentProgramme."from http://stats.uis.unesco.org/unesco/TableViewer/document.aspx?ReportId=289&IF_Lang uage=eng&BR_Country=4580&BR_Region=40515. 21. WorldHealthOrganization(2001).Burdenofmentalandbehaviouraldisorders.The worldhealthreport:2001:mentalhealth:newunderstanding,newhope.Geneva,World HealthOrganization:1944. 22. WorldHealthOrganization(2002).Selfdirectedviolence.WorldReportonViolenceand health.E.Krugande.al.Geneva,WorldHealthOrganization:185212. 23. WorldHealthOrganization.(2007)."InternationalClassificationofDiseasesandRelated HealthProblems."10thRevision. 24. WorldHealthOrganization.(2008)."Suicideratesper100,000bycountry,yearandsex fortheyear2007."from <http://www.who.int/mental_health/prevention/suicide_rates/en/index.html>.

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