Chitsanzo Mafuta MPhil Public Mental Health Fellow University of Cape Town

“All too often, suicide represents a tragic consequence of failing to diagnose and treat serious mental illness” Dr. Anders Nordstrom, Acting Director-General of WHO (2006)

Introduction Suicide is defined as an act with fatal outcome that is deliberately initiated and performed by the person in the knowledge or expectation of its fatal outcome 1 Suicide methods include: – Drug overdose, poisoning – Hanging, Drowning – Gunshot – Jumping from heights, onto or from running vehicles 1 Gelder, M., Harrison, P., & Cowen, P. (2006). Shorter Oxford Textbook of Psychiatry.(5 th Edition). New York: Oxford University Press

Epidemiology  Every year 1 million people die from suicide; a global mortality of 16 per 100,000, or 1 death every 40 seconds 2  In Malawi: 2,269 deaths (1.09% of total deaths)  Aged adjusted death rate is per 100,000 of population ranks Malawi #6 in the world 3  Suicide is #16 as cause of death in Malawi 3 WHO (2011). Malawi: Suicide. Accessed on April 15, Available on World Health Organization: Suicide Prevention. Accessed on April 17, Available on

Laws in individual jurisdictions Malawi, Kenya, Nigeria, Rwanda, Tanzania, Ghana and Uganda are among other African countries that currently criminalize nonfatal suicidal behavior 5 In Malawi, suicide attempters have been convicted and sentenced to several months or years of imprisonment with hard labour 5 Kanjo, M. (2011, February 25). Why is suicide a crime? Retrieved from acrime&catid=236:think acrime&catid=236:think

Laws in individual jurisdictions  In Zambia 6, Zimbabwe 7, UK and Wales 8, suicide is not a crime  The laws of these countries are against inciting and assisting suicide 6 Suicide Act, 1967 of Zambia 7 Criminal Law Code, 2004 of Zimbabwe 8 Suicide Act, 1961 of England and Wales

Link between Suicide and Mental illness Suicide is a multidimensional disorder 9 Between 40% - 60% of people who commit suicide saw physician in the month prior to suicide Overall prevalence of mental disorders is % in cases of completed suicide Lifetime risk of suicide in people with – Mood disorders (chiefly depression) is 6-15% – Alcoholism, 7-15% – Schizophrenia, 4-10% 9 WHO (2009). Preventing Suicide: A Resource for General Physicians. Geneva

Who is at risk of suicide? Higher risk groups: Gender: 3 times common in men than women Marital Status: Never married, widowers, widows, & divorced Professions: (vets, pharmacists, farmers, doctors) Previous History of attempts Psychiatric Disorder or substance abuse Experience of stressful life events 10,11 10 Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press. 11 Joiner, T. (2010). Myths about suicide. Cambridge, MA: Harvard University Press.

Who is at risk of suicide? People who experience stressful life events 10,11 – family and interpersonal conflicts, – relationship breakdowns, – other interpersonal difficulties, – the presence of legal/disciplinary problems, – financial and job difficulties – Severe physical illness – Bereavement – Childhood trauma 10 Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press. 11 Joiner, T. (2010). Myths about suicide. Cambridge, MA: Harvard University Press.

Stress-Vulnerability Model VULNERABILITY + STRESS -/+ COPING STRATEGIES = DISTRESS (mental health problem)

Evidence from Malawian Media Reports  Electronic search of articles on suicide cases carried out in Malawi since inception of online newspapers (late 2006)  Eligibility criteria Age; Sex; Method; Reason for committing suicide or associated factors; & outcome  30 cases were found  Thematic approach was used to analyze data

Results  25 males; 5 females  Age range: 15 – 86 yrs  Mean: yrs (SD )  Suicide methods used Hanging: 27 cases (90%) Drug overdose: 1 case (3.3%) Stabbing: 1 case (3.3%) Gunshot: 1 case (3.3%)

Results continued  Outcome Completed: 29 cases (96.7%) Attempted: 1 case (3.3%)  Psychosocial stressors Relationship problems Poverty related Chronic physical illness, Chronic psychiatric illness, Positive HIV status Excessive alcohol use Fearing to be arrested Unknown but associated factors, single parenthood and alcohol use

Age

Suicide Methods

Psychosocial Stressors

Limitations Print newspapers were not included Failed to get all reported cases because did not meet eligibility criteria Sample is too small to generalize the findings

Discussions Use of media reports is one approach to understand suicide in developing countries like Malawi which usually have no organization acting as central suicide registry 12 Central Suicide registry is important for a country in order to understand burden and develop proactive strategies 12 Adinkrah, M. (2011). Epidemiologic characteristics of suicidal behavior in contemporary Ghana. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 32,

Discussions Motivation or stressors for suicide in this review are consistent with several studies 11,10,14 Findings of suicide methods are different to hospital-based study which revealed pesticide poisoning, 66 cases out of 84 (79%) and self immolation Dzamalala, C. P., Milner, D. A., & Liomba, N. G. (2006). Suicide in Blantyre, Malawi ( ). Journal of Clinical Forensic Medicine, 13 (2): Adinkrah, M. (2012). Criminal Prosecution of Suicide Attempt Survivors in Ghana. International Journal of Offender Therapy and Comparative Criminology. Accessed on April 17, Available on

Conclusion Suicide is indeed huge but preventable public health problem It requires a concerted public health response to reduce suicide by reducing mental illness Mental health problems indeed constitute major risk factor for suicide

Recommendations  Establishment of central suicide registry  Comprehensive research on extent of suicide in Malawi Psychological autopsies Epidemiological studies  Revise current pathway to carecurrent pathway to care

Food for thought Is decriminalization or depenalization of suicide important in Malawi?