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Suicide among the youth in Malaysia: What do we know?

Article  in  Asia-Pacific Psychiatry · November 2014

DOI: 10.1111/appy.12162 · Source: PubMed

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Suicide Among Youth in Malaysia: What Do We Know?

Published in Asia-Pacific Psychiatry 7 (2015) 223–229
Norharlina Bahar1 MD[UKM] MMED(Psych)[UKM] Child Adol Psych[VIC],
Wan Salwina Wan Ismail 2, MBBS[Adelaide] MMED(Psych)[UKM], Adv Master Child Adol Psych[UKM]
Nurulwafa Hussain1 MBBS[UM] MMED(Psych)[UKM],
Jamaiyah Haniff3 MD[UKM] MComHealth[UKM] MSc (Clin Epid)[NIHES],
Mohamad Adam Hj Bujang3 BSc[UiTM] MBA[UiTM],
Abdul Muneer Hamid3 BA[UKM],
Yusni Yusoff4 MD[UKM] MMED(Psych)[UKM],
Norhayati Nordin5 MD[UKM] MMED(Psych)[UKM] Child Adol Psych[VIC],
Nor Hayati Ali 1 MD[UKM] MMed(Psych)[UKM] MIMH[UniMelb]

1 Department of Psychiatry and Mental Health, Hospital Selayang, Batu Caves, Selangor, Malaysia
2 Department of Psychiatry, Faculty of Medicine, UKM Medical Center, Cheras, Kuala Lumpur, Malaysia
3 Clinical Research Centre, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
4 Department of Psychiatry and Mental Health, Hospital Pulau Pinang, Malaysia
5 Hospital Mesra Bukit Padang, Kota Kinabalu, Sabah, Malaysia

Author for correspondence:

Dr. Norharlina Bahar
Consultant Child and Adolescent Psychiatrist
Department of Psychiatry and Mental Health
Hospital Selayang
68100 Batu Caves Selangor
Tel.: 03- 61263800
Fax: 03- 61207564
E-mail: norharlinab@selayanghospital.gov.my

Approx. 3528 words

ABSTRACT
Introduction: The National Suicide Registry Malaysia was established to gather data on completed
suicides in Malaysia from all forensic departments under the purview of Ministry of Health Malaysia.
Methods: This paper describes all suicides in youth reported to NSRM from 1 January 2009 to 31
December 2009.
Results: The suicide rate among youth was 1.03 per 100,000 population in 2009, with male gender and
Indians being the highest suicide completers. The most common method of suicide was hanging, followed
by self-poisoning. Mental and physical illnesses, family history of mental illness and previous suicide
attempt were surprisingly not common among the suicide completers.
Discussions: Suicide rate among Malaysian youth is relatively lower compared to other countries in the
Asian region. This is possibly due to the under-reporting of suicide cases due to cultural, legal and religious
factors.
Conclusion: Suicide is a very complex, multifaceted problem, requiring prevention at all levels,
particularly targeting the youth.

Key words: suicide, Malaysian youth, suicide registry

 2

Introductions

Suicide or self-inflicted death among youth is a serious problem worldwide. It is one of the leading causes
of death among youth (Wasserman et al. 2005). The trend is increasing, particularly in the non-European
countries (Wasserman et al. 2005).
Suicide in the youth is linked to various risk factors. Social and academic disadvantages,
psychopathology and mental illness in the individuals, family history of mental illness and stressful life-
events (Beautrais 2000, Agerbo et al. 2002; Gould, 2003) have been implicated. Mental illness has turned
to be the strongest factor contributing to suicide among this young population (Agerbo et al. 2002).
In a sample of 55 children and adolescents who were compared with 55 community controls,
depressive disorders, substance related disorders and disruptive disorders have been found as significant
predictors for suicide in children and adolescents (Renaud et al. 2008). It was reported further that
individuals with psychopathology and previous high level of functioning, but internalize their conflicts
were at risk of completed suicide (Gagnon et al. 2009). History of suicide and early death in the parents,
and parental mental illnesses were also associated with increased risk of suicide in the young people
(Agerbo et al. 2002).

Culture has a strong influence on suicidal behavior. The role of family, religions, and the different
manifestations and interpretations of distress in the different cultural context determine suicidal behavior
(Goldston, 2008).
Suicide trend in developing countries in the Asian region is different from the western population (Milner
& De Leo, 2010). In the unique Malaysian culture, suicide needs to be understood in its own cultural
context in order to curb the problem more efficiently. There is paucity of suicide research locally, and
most research had studied the adult population (Bhupinder et al. 2010; Chan et al. 2011; Maniam, 1988;
Maniam, 1994; Nadesan, 1999) with very little focus on the younger population. This paper reports the
descriptive data on youth suicide in Malaysia based on National Suicide Registry Malaysia (NSRM) data for
2009.

Method

This is a registry-based study using records from National Suicide Registry Malaysia from 1st January to
31st December 2009. NSRM which was launched in 2007, aimed to gather nationwide data on suicide in
Malaysia. Information was gathered from close relatives using a structured Case Report Forms (CRF). It
consists of socio-demographic variables, death history and risks factors. Cases are classified according to
Chapter XX of ICD-10 i.e. External Causes of Mortality and Morbidity (codes X60 - X84) (World Health
Organization, 2007). The diagnosis of suicide is based on a post-mortem examination of the dead body
and other supporting evidence that shows a preponderance of evidence indicating the intention to die.
Only suicide cases by the youth i.e. aged 15-24 years as defined by the WHO were included in this study.
Details on methods have been reported elsewhere (Hayati & Kamarul, 2008).

Statistical Analysis
This is population based data in a year 2009 and therefore no statistical inference was done. All the
analyses were presented in frequency with percentage. Column percentage was used for every cross
tabulation analysis. All analyses were carried out using STATA (College Station, Texas 77845 USA). The
suicide rate per year is the number of suicidal deaths recorded during the calendar year divided by the
total population at risk, as reported in the official Malaysian National Statistics Department census figures
and multiplied by 100,000 (World Health Organization, 2009)
Results
 3

In the year 2009, there were 54 people below the age of 25 reported to have completed suicides. The
suicide rate for youth generated by this registry is 1.03 per 100,000 population.

Table 1 illustrates the sociodemographic features of these youth. About 88.6% were Malaysian
citizens. In terms of gender, there were more males (66.0%) compared to females (34.0%). Indians were
the highest (35.9%) followed by Chinese (24.5%), Malays (18.9%) and others (7.6%). Religion is reflected
by ethnicity, the highest being among Hindus. Most suicide completers were single, had secondary
education and employed. There were six missing data on ethnicity and two on employment status. The
youngest age was a 14 year-old girl. She was a fulltime student died from pesticide poisoning (possibly
organophosphate). She did not disclose her intent prior to her act, and had no previous attempt. She did
not have any history of substance abuse either. There was no history of physical or mental health problem,
and there was no family history of suicide. It was documented that she had intimate partner problem.

Method of suicide was described in Table 2. The most common suicide method among the young
people in Malaysia was hanging, strangulation and suffocation, which accounted for 30 victims. This is
followed by intentional self-poisoning by or exposure to pesticides (15.1%), drowning and submersion
(5.7%) and from jumping from a high place (5.7%). Two persons died from poisoning or exposure to
unspecified chemicals and noxious substances (3.8%), and by smoke, fire or flames (3.8%) and by sharp
object (3.8%) respectively. One person used exposure to nonopiod analgesic, antipyretics and anti
rheumatics (1.9%); exposure to organic solvents, halogenated hydrocarbons and their vapours (1.9%) and
exposure to other gases and vapours (1.9%), respectively.

Past History of suicide, physical and mental health problems, and family history of suicide were
described in Table 3. Interestingly, most of the suicide completers did not report past history of attempted
suicide, physical and mental health problems as well as family history of suicide.

Discussions

We set out to describe the rate and profile of youth with completed suicide in Malaysia in 2009. This is
because the incidence of suicide among youth in Malaysia is on an increasing trend. According to the
National Suicide Registry 2008, the suicide rate among youth (10-19 years of age) was 0.56 per 100,000
population and a year later, when examining the suicide rate under the age of 25, we found it has
increased to 1.03 per 100,000 population. It may not be a direct comparison, but the increase may be
partly contributed by the rapidly growing nation, resulting in social and cultural changes. In most families,
both parents have to work to meet their financial needs. The protective factor of the used to be ‘extended
families’ weakens as families become more nucleated. The youth are put under pressure to achieve
academic excellence in order to survive in the rapidly changing and competitive society.

In Malaysia and few other Asian developing countries, the pressure to succeed in exams has been
described as the cause for suicide among young people. The shame associated with failure to excel and
compete academically, lead them to attempt and complete suicide (Vijayakumar et al. 2005).

Nevertheless, the rate is relatively lower compared to other countries in the Asian region (Wu et
al. 2012). This is most probably contributed by the non-reporting and under-reporting of suicide cases in
Malaysian due to the cultural, religious as well as legal factors. Suicide is culturally a taboo, thus reporting
is avoided in order to protect families from shame and stigma (Wu et al. 2012). The fact that suicide is
 4

illegal under Section 309 of the Malaysian Penal Code, further forbid the reporting of such cases. The
misclassification of suicide cases is perhaps another factor contributing to the lower rate. Medically
certified suicide cases which might be misclassified as ‘violent death from undetermined cause’, had
resulted in the drop of suicide rates in Malaysia from 1975 (Maniam, 1995).

In support with previous findings (Bridge et al. 2006; Bilsker &White, 2011), this study also found
more males than females who completed suicide among the Malaysian youth. Gender differences in
suicide may be associated with the method used, cultural acceptability and psychosocial differences
between the two gender (Beautrais, 2002; Beautrais, 2003; Bilsker & White, 2011). Impulsivity (Eisenberg
et al. 2005) and aggression (Beautrais, 2003), which are more commonly reported in males have also been
implicated to predispose to suicide (Turecki, 2005; Dumais et al. 2005). In a sample of Cambodian
teenagers, males were reported to have more suicidal plan compared to their female counterparts
(Jegannathan & Kullgren, 2011) reflecting their strong intent to die. It is speculated that men who
completed suicide were more hopeless and intent about dying, (Bilsker & White, 2011) which influenced
their choices of lethal methods. Gender differences in suicide is an important yet a complex issue that
requires more understanding.

Malaysia is a multiracial society comprises Malays as the majority, followed by Chinese and
Indians, the choice of religions is largely reflected by the ethnicity. Indians are the highest suicide
completers (35.85%) compared to Malays who are the lowest (18.87%). Suicide is clearly forbidden in
Islam thus indirectly prohibited the Malays who are majority Muslims from carrying out the act of suicide
which is against the religion (Maniam, 2003). Conversely, Indians who are mainly Hindus lack the strong
religious prohibition thus suicide is perceived as more acceptable for them. It was also hypothesized that
Indians as the ethnic minority have more risk factors such as social deprivation and alcoholism, hence at
higher risk of suicide (Maniam, 2003). On the other hand, the Chinese are protected to certain extent by
their religious-cultural traditions. Suicide is considered as a sin in Christianity while Buddhism forbids it as
well (Maniam, 2003).

The method of suicide among youth in Malaysia has been stable over the years (NSRM, 2007;
NSRM, 2008). Hanging is the most common method of suicide, followed by self-poisoning, which happens
to be the trend seen in other Asian countries as well (Wu et al. 2012). These may be attributed to the easy
availability of hanging appliances, as well as accessibility to pesticides and other poisons in Malaysia.
Hanging does not require specific appliances but any suitable items which are readily available can be
used. It is popular among the youth who may not have the financial abilities or access to more expensive
methods. Although Malaysia has transformed into an industrialized nation, agriculture remains an
important contribute to the country’s economy, thus pesticides are still widely available. We do not have
the details but there is a possibility that the three victims were from the farming areas where pesticides
were readily accessible. In the near future, jumping from high building may become a more common
method with the increase in high-rise buildings particularly in urban areas like Kuala Lumpur. This is
evident in Singapore (Chia et al. 2011) where most of the people live in high rise buildings.

Mental illnesses in the individuals and their families, previous suicide attempts and physical
illnesses have been shown as risk factors for youth suicide (Beautrais, 2000; Beautrais, 2003; Agerbo,
2002 ; Masango et al. 2008). Contrary to this, we found that majority of the youth in this study were
reported not to have any mental illnesses (69.8%), nor any family history of mental illness (67.92%), or
previous suicide attempts (69.8%) and physical health problems (71.7%). A possible explanation is that
family members interviewed might not be aware of the above problems in the deceased. There is a strong
stigma attached on mental illnesses (Ng, 1997; Tuti et al. 2009) thus it is not uncommon that the diagnoses
 5

are often delayed or undiagnosed. In approximately 20-22% of the suicide cases reported in the registry,
close relatives admitted to not knowing whether the deceased had the problems mentioned.

Although mood disorders were frequent diagnoses found among youth involved in completed
suicide (Fleischman et al. 2005, Yoshimasu et al. 2008), none were reported to have depressive disorders
in the registry. Among those known to have mental health problems, two were diagnosed as
schizophrenia, one had personality disorder and another one had mental retardation, while diagnoses
were uncertain in two other cases. It is possible that mood disorders were undetected thus not diagnosed
among the deceased. A depressed adolescent may be overlooked since mood changes is common during
adolescence (Rey, 1995), hence not given serious attention. In contrast, it is more difficult for symptoms
of schizophrenia such as delusion, hallucination and aggression to go unnoticed. In consequence,
overcoming stigma to ensure early diagnosis and proper treatment of mental illnesses is an important
early step to prevent suicide among the young people.

Early detection of mental illnesses is important given the frequent occurrence among youth who
completed suicide (Yoshimasu et al. 2008, Renaud et al. 2008). In consequent, overcoming stigma to
ensure early diagnosis and proper treatment of mental illnesses may prevent suicide among the young
people.

Suicide among youth in Malaysia needs to be taken very seriously as the actual numbers of death
can be alarming. It has to be understood in its unique social and multi-cultural context. The NSRM is the
first important step towards understanding the reality of suicide among youth in Malaysia. Nevertheless,
measures are required to improve the process so that the data obtained can be optimized and used to
the best. There is a definite need for more research in this area to understand the unique features of
suicide in the local context. Measures should be taken to overcome the cultural barrier and stigma in
order to increase awareness and reporting among the people. Then only, the suicide preventive strategies
can be improved, taking into consideration the cultural and religious sensitivities of the multicultural
Malaysian society.

Limitations
The main limitation is the incomplete data compiling. Although NSRM have been launched for more than
five years, we are still lacking data from some states in Malaysia, thus these results might not reflect the
true incidence rate of suicide among youth nor their profile. Cultural and religious taboo prevent
reporting, consequently leaving many cases undetected.

Conclusion

The rate of suicide in Malaysian youth is alarming. This is worrying particularly in the Malaysian culture
whereby suicide is a sensitive issue. Preventive measures are very important to curb the rising rate.
However, existing ongoing suicide preventive activities for youth in Malaysia, is still lacking. This is very
important as youth is the future of the country. Preventive strategies should target to break the taboo
and provide support to those in needs.
 6

Acknowledgement

We would like to thank Ministry of Health Malaysia for funding and providing governance for this project;
the Clinical Research Centre of Malaysia and all the Forensic Units and Departments which had made this
data available.

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Table 1. Sociodemographic features of youth who completed suicide in 2009, Malaysia

N (%)
Gender
Male 35 (66.1)
Female 18 (34.0)
Ethnic
Chinese 13 (27.7)
Iban 1 (2.1)
Indian 19 (40.4)
Malay 10 (21.3)
Others 4 (8.5)

Religion
Buddhism 14 (26.4)
Christianity 3 (5.7)
Hinduism 19 (35.9)
Islam 14 (26.4)
Others 3 (5.7)
Marital status at time of death
Married 6 (11.3)
Single 45 (84.9)
Unknown 2 (3.8)
Highest completed education
None 2 (3.8)
Others 4 (7.6)
Primary 7 (13.2)
Secondary 39 (73.6)
Tertiary 1 (1.9)
Employment status at time of death
Disabled, permanently sick 1 (1.9)
Full-time employed 19 (35.9)
Full-time student 8 (16.0)
Housewife/ homemaker 2 (3.8)
Others 2 (3.8)
Part-time employed (including self-employed) 3 (5.7)

Temporary work 5 (9.4)

Unemployed 11 (20.8)

Citizenship
Malaysian 47 (88.7)
Non Malaysian 6 (11.3)
 10

Table 2. Method of suicide of youth who completed suicide in 2009, Malaysia

Variables N (%)
Method of suicide
ISP by and exposure to nonopiod analgesic, antipyretics and anti rheumatics 1 (1.9)

ISP by and exposure to organic solvents and halogenated hydrocarbons and 1 (1.9)
their vapours
ISP by and exposure to other gases and vapours 1 (1.9)
ISP by and exposure to pesticides 8 (15.1)
ISP by and exposure to other and unspecified chemicals and noxious 2 (3.8)
substances
ISH by hanging, strangulation and suffocation 30 (56.6)
ISH by drowning and submersion 3 (5.7)
ISH by smoke, fire and flames 2 (3.8)
ISH by sharp object 2 (3.8)
ISH by jumping from a high place 3 (5.7)

*Intentional self-poisoning (ISP), Intentional self-harm (ISH)

Table 3. Past History of youth who completed suicide in 2009, Malaysia

Variables N (%)
Attempted suicide previously
No 37 (69.8)
Yes 6 (11.3)
Unknown 10 (18.9)
Physical health problems
No 38 (71.7)
Yes 3 (5.7)
Unknown 12 (22.6)
Mental health problems
No 37 (69.8)
Yes 6 (11.3)
Unknown 10 (18.9)
Family history
No 36 (67.9)
Yes 5 (9.4)
Unknown 12 (22.6)

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