SUICIDE AND MENTAL ILLNESS IN SINGAPORE

Vl. 15, N. 3. SINGAPORE MEDICAL JOURNAL 191 September, 1974. SUICIDE AND MENTAL ILLNESS IN SINGAPORE By W. F. Tsi and B. H. Chia SYNOPSIS This is a study f 112 cases f suicides wh had a past histry f being admitted t a mental hspital in Singapre. Only 16% f all the suicides in Singapre ver the perid 1969 t 1972 had such a histry. Cmpared with the randm cntrl there is a prepnderance f females and Chinese. Clinically the suicide grup was slightly yunger and had mre disturbed and aggressive histries. 78% were diagnsed as Schizphrenia which is a striking cntrast with a similar study in Bristl, England in which 62% were diagnsed as Psychtic Depressin. Of the Schizphrenic cases in ur study 65% had suffered frm the illness fr less than 5 years and 52% cmmitted suicide within three mnths f discharge frm the hspital. Cmpared with all suicides in Singapre there was a definite increase in suicide by drwning and verdsage f drugs by Schizphrenic patients. This study brings ut sme psitive factrs related t Suicide in Mental Illness. INTRODUCTION The impressin btained frm previus studies is that mental illness is an imprtant causative factr in suicide. The many studies which are available shw that a great prprtin f individuals wh have cmmitted suicide have had preexisting mental illness. This prprtin was reprted in recent years t vary frm 18 % in Delhi by Singh, et al (1971), t 24% in Western Nigeria by Asuni (1962), t 37% in Singapre by Chia and Tsi (1972), t 66% in Bristl, England by Seager and Fld (1965) t a peak f 94% in St. Luis, U.S.A. by Rbins et al (1959). Such wide variatin in percentages may stern frm differing criteria accepted as evidence f mental illness, but it may, als be due partly t different psychlgical, cultural, scial and envirnmental factrs. The latter reasns fr this wide variatin culd nly be established if the criteria used by the authrs in frming diagnses are mre standardized and bjective. It is unlikely that such an ideal situatin can be reached in the near future. Chia and Tsi (1972) in their study f "Suicide in Singapre" fund that 16.5 % f the ttal cases had received inpatient psychiatric treatment in a psychiatric hspital (Wdbridge Hspital). Admissin t a psychiatric hspital in Singapre usually indicates the presence f fairly severe vert psychiatric disrder, usually f a psychtic nature. W. F. TSOI M.B., B.S. (Sing.), M.R.C.P. (Glas.), D.P.M. (Eng.), Medical Superintendent. Wdbridge Hspital, Singapre 19. B. H. CHIA, M.B., B.S. (HK.), D.P.M. (Eng.), Private Psychiatrist. 24 Liat Twers, 541 Orchard Rad, Singapre 9. MATERIAL AND METHODS All the cases in which a verdict f Suicide during the perid 1969 t 1972 (inclusive) were returned by the crners in Singapre were examined. Thse cases which had a histry f inpatient -treatment in Wdbridge Hspital (the nly mental hspital in Singapre) were selected ut and their medical case files were studied by ne f us (WFT) and the necessary facts btained. Attentin was paid t the diagnses, pattern f clinical presentatin and utcme, and previus suicide attempts. Similar studies were made frm the cases admitted just befre and just after the first admissin t Wdbridge Hspital f the cases wh has cmmitted suicide t serve as the "randm cntrl" ppulatin. A ttal f 132 cases (15.8% f all suicides) has a past histry f admissin t Wdbridge Hspital, but nly 112 cases (85 %) culd be traced and studied. RESULTS Age, Sex and Race These are shwn in tables II and III. The suicide ppulatin tends t be yunger. There is a slight prepnderance f females. These are cntrary t what is nrmally expected frm the ttal suicide ppulatin. There are mre single males and mre married females than the "randm cntrl" grup. The rate fr Chinese is higher and fr Malay is lwer than the cntrl. HOUSING ESTATES The percentage f psychiatric patients staying in Singapre Husing and Develpment Bard husing estates wh cmmitted suicide (17 %) was fund in this study t be lwer than the cntrl ppulatin wh did nt cmmit suicide (23 %). This

192 SINGAPORE MEDICAL OD RNAL TABLE I Year 1969 1970 1971 1972 Ttal N. f Suicides in Singapre 188 185 230 236 839 N. f Suicides with past admissin t mental hspital 31 31 31 39 132 Percentage 16.5% 16.7% 13.5% 16.5% 15.8% TABLE II AGE AND SEX Age Sex Male Female Ttal Cmparisn Percentage f Percentage f ttal suicide ttal cntrl 10-19 yr. 10 16 26 23 % 16 % 20-29 yr. 21 18 39 35 % 35 % 30-39 yr. 14 19 33 29 % 31 % 40-49 yr. 50+ yr. 8 6 14 13 % 18 % TOTAL 53 59 112 100 % 100 % TABLE III RACE AND SEX Race Sex Male Female Ttal Cmparisn Percentage f Percentage f ' ttal suicide ttal cntrl Chinese Indians Malays Others 48 5 52 5 2 100 10 2 89% 9 % 2% 0 0% a 77 % 12% 9% a 2% TOTAL 53 59 112 100 100 again cnfirms the impressin f Chia and Tsi (1972) that staying in such Husing Bard flats des nt increase the suicide risk f the ppulatin even amng the severely mentally ill. CLINICAL FEATURES There are mre cases with histries f aggressive and restless behaviur in the suicide grup than in the cntrl. Mre f them are als reprted t have symptms f auditry hallucina- tins and paranid ideas and delusins. There is als a definitely higher incidence f previus suicide attempts in the suicide grup cmpared t the cntrl grup. 26 % f suicide cases made suicide threats r entertained suicidal ideas cmpared t 10% f the cntrl. The ttal percentage f the suicide grup having electr -cnvulsive therapy (54%) is higher than the ttal percentage f cntrl grup (42%). There is n striking difference in the incidence f physical illness in the tw grups.

SEPTEMBER, 1974 193 DIAGNOSIS This is shwn in Table IV. The randm cntrl ppulatin shuld give a fairly accurate picture f the diagnstic distributin f the new admissins int Wdbridge Hspital. The majrity f the cases are Schizphrenia (61.5%) and nly (2.7%) are diagnsed as Affective psychsis. A cmparisn with the suicide ppulatin shws that the percentage f Schizphrenia is even higher (77.6%). It is difficult t cmment n the Affective grup because f the small number. This pattern is in striking cntrast with that btained by Fld and Seager (1968) wh fund nly 7 % Schizphrenia but 62% Psychtic Depressin which is equivalent t Affective Psychses in the suicide grup, and 15% f Schizphrenia but 32 % Psychtic Depressin in his cntrl grup. (See Table V). Such marked cntrast culd be partly due t differences in mental disease pattern between Singapre and Bristl and partly due t attitudes f Psychiatrists twards a diagnsis and treatment t Schizphrenia and Affective Psychsis. Anther imprtant factr is the attitude f the cmmunity twards inpatient treatment f less disturbing mental patient. The ther interesting findings are the high suicide risk f patients suffering frm Puerperal Psychsis and the lw suicide risk f patients suffering frm Organic Brain diseases. All the 4 cases f Organic brain diseases wh cmmitted suicide were female and the diagnses were: Epileptic psychsis 3 cases, and G.P.I. 1 case. There is nly I case f a male Alchlic. Because f the large numbers f Schizphrenia, this is sught ut fr further analysis. SCHIZOPHRENIA AND SUICIDE In this study 87 cases (78 %) in the suicide - grup and 138 cases (62%) in the cntrl grup are fund t suffer frm Schizphrenia. There are mre Paranid Schizphrenia in the suicide grup (18%) than in the cntrl grup (I1 %). The sex rati f the suicide grup is I.1 male t 1 female cmpared t I.5 male t 1 female in the cntrl grup. The mean age f first admissin int Wdbridge Hspital fr the suicide grup is 30 years and fr the cntrl grup is 30.5 years. There is n characteristic time when the suicide takes place during the Schizphrenic illness except that the number f cases drps rapidly as the illness becmes chrnic. This is shwn in greater detail in table VI. Such a trend is understandable because Schizphrenia weakens a persn's vlitin and drive as the disease prgresses. Mre than 50% f the cases cmmitted suicide within the first three mnths after discharge frm hspital. This is similar t the findings f Fld and Seager (1968) in their series cnsisting largely f psychtic depressins. It appears that the experience f hspitalisatin and the realisatin by the patients f suffering frm a series illness have smewhat cntributed t their suicidal deaths during the TABLE IV DIAGNOSIS Diagnses Male Female Ttal Cmparisn Suicide (/) Cntrl (%) Ttal fr Organic Psychses 0 4 4 3.6 11.2 Schizphrenia 45 42 87 77.6 61.5 Psychtic Depressin 3 3 6 5.4 2.7 Puerperal Psychsis - 5 5 4.5 2.2 Ttal fr Functinal Psychses 48 50 98 87.5 76.4 Neurtic Depressin 3 5 8 7.1 9.8 Other Neursis 0 0 0. 0 2.7 Persnality Disrder I 0 1 0.9 4.5 Ttal fr Neursis 4 5 9 8.0 17.0 Others 1 0 1 0.9 5.4 TOTAL 53 59 112 100 100

194 SINGAPORE MEDICAL JOURNAL TABLE V COMPARISON WITH RESULTS FOR BRISTOL Diagnsis Schizphrenia Affective Psychsis Others Singapre (%) Suicide Cntrl 77.6 61.5 5.4 2-7 17.0 35.8 Suicide Bristl (%)* Cntrl 7 15 62 32 31 53 *Mdified frm Table I Page 445 Fld and Seager (1968) TABLE VI DURATION OF ILLNESS AND SUICIDE (f Schizphrenia)* Time between First Admissin and Suicide Male Female 'Ttal Percentage Up t 5 years 32 23 55 65.4 5 t 10 years 8 16 24 28-6% 10 t 15 years 2 1 3 3-6% 15 t 20 years 2 0 2 2-4% TOTAL 44 40 84 100% *Infrmatin n 3 cases is nt knwn. early stages f their illness when insight and vlitin are relatively unaffected. Details f the relatinship between discharge frm hspital and suicide is shwn in table VII. METHODS OF SUICIDE BY SCHIZO- PHRENIA As shwn in table VIII, cmpared t all suicides in Singapre, there is a definite increase in drwning and verdsage f drugs by Schizphrenic patients and less in hanging and pisning by dmestic pisns. Analysis by sex shws that the lw number f hanging is cnfined t the males nly, whereas fr dmestic pisning this lw number is cnfined t the females nly, in which there is nt a single case. The general impressin btained frm the study f the cases indicates that the Schizphrenic patients are nt as determined as the severely depressed patients in their suicidal act. It appears that suicidal acts fr the Schizphrenic patients are impulsive and less sustained. Often because f their cnfused and disturbed mental state, sme f the "suicides" culd be cntributed by accidental factrs. This prbably accunts fr the high incidence f drwning and jumping (which d nt require much planning r effrt) amng such patients. Such patients als have greater access t psychtrpic drugs it is nt surprising that drug pisn as a methd f suicide is three times higher in this grup than in the general ppulatin. DISCUSSION AND CONCLUSION The study f suicides in large numbers can nly be carried ut psthumusly thrugh interviews with relatives. In this study a grup f patients is selected in which their mental health has been a subject f examinatin at varying perids prir t the suicide act. Being a retrspective study, many f the case ntes may nt cntain the infrmatin which the psychiatrists cnsider relevant in understanding suicide behaviur amng mental patients. Hwever, it is hped that results btained frm this study will enable a mre cinprehensive and revealing study t be cnducted in the future. In this study, the striking finding is the marked difference in the diagnstic distributin f psychiatric illness between Wdbridge Hspital in Singapre and in hspitals in Britain. The reversal f the Schizphrenia and Manic-depressive pattern between these cuntries can be due t a number f factrs. The lw percentage f Depressives in Wdbridge Hspital in Singapre can be explained by the Asian attitude twards"depressive Illness" and their management, and the histrical

SEPTEMBER, 1974 195 TABLE VII SUICIDE AND DISCHARGE FROM HOSPITAL (f Schizphrenia)* Duratin f Discharge Male Female Ttal Percentage Up t 3 mnths 26 19 45 52.3 3 t 6 mnths 3 9 12 14.1 6 t 12 mnths 5 5 10 11.6% Mre than 12 mnths 11 8 19 22.0 TOTAL 45 41 86 100 *Infrmatin n 1 case is nt knwn TABLE VIII METHODS OF SUICIDE COMPARING SCHIZOPHRENIA OF WOODBRIDGE HOSPITAL AND SINGAPORE POPULATION Methds Male % Schiz. S'pre ppulatin Schiz. Female % S'pre ppulatin Schiz. Ttal S'pre ppulatin Jumping 50.0 41.6 48.8 48.0 49.4 44.9 Hanging 20.5 38.6 26.8 22.7 23.5 30.7 Drwning 11.4 34 9.8 4.5 10.6 3.8 Overdsage f Drugs 4.5 2.6 9.8 2.0 7.1 2.3 Dmestic Pisns 11.4 6.2 0.0 17.5 5.9 11.9 Others 2.3 7.9 4.8 5.3 3.5 6.6 TOTAL 100 100 100 100 100 100 develpment f Wdbridge Hspital which is lked upn as a hspital fr the acutely mentally disturbed patients. In spite f this attitude and ther selective factrs, this study cnfirms the finding f Chia and Tsi (1972) that in Singapre the mental illness that accunts fr the highest number f suicides is Schizphrenia. Pkrny (1964) f U.S.A. and Stengel (1964) f U.K. cncluded that Depressive illness was the mental illness with the highest suicide risk. Sainsbury (1955) stated that there was a remarkable cnsensus that ne in every six patients diagnsed as Manic-depressive wuld die frm suicide. Hwever, as early as 1933 Lewis drew attentin t the fact that Schizphrenia was the frequently ptential suicide and that the ld beliefs that the Depressive Psychsis had mre r less mnplized that right t cmmit suicide wuld require revisin. Osmnd and Hffer (1967) cmmented that the present emphasis upn the Affective psychsis (Depressive Illness) as the main psychiatric illness assciated with suicidal risk was misplaced and ught t be changed. Levy and Suth - cmbe (1953) basing their study f 58 suicides wh had been patients f a mental hspital fund 29 cases (50 %) diagnsed as suffering frm Schizphrenia. The ther striking finding is the marked different rates f suicide amng the different racial grups in Singapre. Murphy (1954) and Chia and Tsi (1972) nted the extremely lw rate f suicide amng the Malays and the high rate amng the Chinese in Singapre. This study further shws that the suicide rate amng the severely mentally ill Malays is als the lwest (see table III). This appears t indicate that different cultural and religius beliefs and values wuld als influence the rates f suicide in the severely mentally ill.

196 SINGAPORE MEDICAL JOURNAL Methds f suicide vary with different cuntries. Methds mst frequently adpted wuld depend n the mst easily available at the time f crises. The impressin is that the patients with marked depressive and paranid features, are the mst determined in their intent t die. They wuld als ften adpt multiple methds in their attempts t achieve success. The infrmatin btained frm this study may give dctrs dealing with patients with severe mental illness an insight int the varius factrs assciated with high suicide risk. Suicides are mre cmmn in patients suffering frm Puerperal Psychsis, Psychtic Depressin r Schizphrenia than ther psychiatric illness. Psitive clinical features wuld be the presence f paranid and depressive symptms and auditry hallucinatins. The illness wuld be f a mre severe degree and the patients mre disturbed and aggressive. Such patients wuld be in the earlier stages f their illness, and wuld have demnstrated sme attempts f suicides in the past. Fr sme f these cases, it appears that suicide is the end stage f their psychtic illness fr which preventin is difficult at the present stage f ur knwledge. REFERENCES I. Asuni, T.: Brit. Med. J., 2. 1091, 1962. 2. Chia, B. H. and Tsi, W. F.: Sing. Med..., 13, 91, 1972. 3. Fld R. A. and Seager, C. P.: Brit. J. Psychiat., 114, 443, 1968. 4. Levy, S. & Suthcmbe, R. H.: J. Nerv. Ment. Dis., 117, 504 1953. 5. Lewis, N. D.: Psychanalyt. Rev., 20, 215, 1933. 6. Murphy, H. B. M.: Med. J. Malaya, 9, 1, 1954. 7. Osmnd, H. & Hffer, A.: J. f Schizphrenia I, I, 1967. 8. Pkrny, A. D.: J. Nerv. Ment. Dis., 139, 499, 1964. 9. Rbins, E., Murphy, G. E., Wilkinsn, R. H., Gassner, S. & Keyes, J.: Amer. J. publ. Hlth., 49, 888, 1959. 10. Sainsbury, P.: "Suicide in Lndn." Lndn, Chapman & Hall., 1955. I1. Seager, C. P., and Fld R. A.: Brit. J. Psychiat., 111, 919, 1965. 12. Singh, K., Jain N. R., Khullar, B. M. P.: J. Indian Med. Assciatin, 1971. 13. Stengel, E.: "Suicide and Attempted Suicide", Harmndswrth, Penguin, 1964.