Abstract A total of 306 patients were admitted to the University Hospital in Kuala Lumpur in 1989 after attempting suicide. Fourteen of them succumbed to injuries. Psychosocial data of 296 patients out of the 306 survivors are reported. Suicidal behaviour is more common in the young and especially amongst the females. Nearly 45.0% of them are from social class IV and V. Persons of Indian ethnic origin a r e overrepresented, while in Malays suicidal behavior seemed to be less common. Self-poisoning was reported to be the commonest method in attempting suicide. Diagnosis of adjustment disorder was made in 58.5%of the patients. Two-thirds of the patients had an intention score of less than 10 on the Pierce’s Scale.
Keywords: Attempted suicide, Kuala Lumpur, self-poisoning.
Attempted Suicide in Kuala Lumpur Mohd Hussain Habil MBBS,
T Ganesvaran FRC Psych Eng, DPM LS Agnes MBBS Department of PsychologicalMedicine Faculty of Medicine University of Malaya Introduction
Results
The rate of suicide for Malaysia was about 3.0 per 100,000 for the year 1986’. However, suicidal behavior is not uncommon. Murugesan and Yeoh did a study on attempted suicide in 1981 in The aim of this study is to look into the existing problems amongst the urban population in Kuala Lumpur. The purpose of the study is also to collect sociodemographic data and study clinical features of patients attempting suicide.
The results are shown in Tables 1,2,3 and 4. There were 197 females compared to only 99 males who attempted suicide in this study. The female to male ratiowas therefore2: 1. The majority of cases were below the age of 39 years, and the highest
Material and Methods
Address for reprints: Dr. H Hussain Department of Psychological Medicine, Faculty of hledicinc, University of Malaya, Lcmbah Pantai, 59101) Kuala Lumpur, hfalaysia
The University Hospital is situated in Kuala Lumpur, the capital of Malaysia. The catchment area in the Klang Valley has a population of about 2.5 million which is made up of 46.0% Chinese, 38.5% Malays, 15.0% Indians and 0.5% others. The people are mainly involved in business and administrative jobs4. Patients admitted to the University Hospital after many forms of self-harm were seen by the casualty medical officers and medical officers from the Psychiatric Unit. The authors interviewed the patients within 24 hours of admission to the hospital when their physical and mental state allowed for it. Some of them were interviewed in the surgical and medical wards, while others were seen in the Psychiatric Unit. Patients’ intention for suicide was assessed using Pierce’s Intention Score’. All patients volunteered to cooperate with the invest igations.
Table 1. Sociodemographicdata of 296 patients who attempted suicide Categories
n
%
Male Female
99 197
33.4 66.6
Marital status Single Married Divorced/separated/ wid owed
145 134 17
49.0 45.3 5.7
Age (years) 0-19 20-39 40-59 60 and above
52 197 37 10
17.6 66.5 12.5 3.4
Racial breakdown Indian Chinese Malays Others
142 120 30 4
48.0 40.5 10.1 1.4
37 50 71 41 97
12.5 16.9 24.0 13.9 32.8
No. of persons
Social class I I1 111
IV V
5
Asia-Pacific Journal of Public Health 199211993 Vo!. 6 No. 2 Table 2. .hIethods of self-harm in 296 patients who attempted suicide Method Used
n
%
Self-poisoningalone (n = 251) Drugs Psychotropic Analgesics Other drugs
52 34 24
17.6 11.5 8.1
Chemicals Detergent Insecticide & Pesticide Agrochemicals Other chemicals Multiple drugs and chemical
35 28 22 7 49
11.8 9.5 7.4 2.4 16.6
Physical methods (n = 45) Cutting and stabbing Hanging Ingestion of foreign objects like stones and blades Bums
1s 11 2
6.1 3.7 0.7
2
0.7
Combinations of physical and self-poisoning
12
4.0
Table 3. Diagnosis of 296 patients who attempted suicide Diagnosis Adjustment disorders Alcohol and drug dependence Schizophrenia Affective disorders and grief Physical disorders and complaints Personality disorders Obsessive-compulsive disorder
n
%
176 38
59.5 12.8
30
10.1 258.5 186.1
8
2.7 10.3
proportion was seen in the category who were unmarried. In terms of racial breakdown, it is remarkable that the majority of those who attempted suicide were Indians. This figure could not be explained by racial distribution since the Indian population in the Hang Valley area is the least when compared to the Chinese and Malays. Even though Malays makeup the second major race in the Klang Valley area, the percentage of those who attempted suicide was small when compared to that of Indians and Chinese respectively. Malays only comprised about 10.0% out of the total number of attempted suicide patients in this study.
Table 4. Intention scores of 296 patients who attempted suicide Intention score
Male n (%)
Female n (%)
Total n (%)
0-4 5-9 10-14 15-19 20-25
1g(6.4) 36( 12.2) 25(8.5) 17(5.7) 2(0.6)
5 1( 17.2) gO(30.4) 38( 12.8) 17(5.7) l(0.4)
70(23.6) 126(42.6) 63(21.3) 34(11.4) 3( 1.0)
6
Based on social class distribution, it was apparent that only a small percentage of those belonging to social class I and I1 were admitted for attempted suicide in this hospital. Theyonlycomprised about 29.0% out of the total number of patients studied. This was in sharp contrast to those who were in the lower social class whose numbers were three times more comparatively. The majority of those who attempted suicide in this study preferred to use self-poisoning or ingestion of chemicals as ways to carry out their attempt. This indicates that such chemicals are easily accessible. The majority attempted suicide in an impulsive manner, without even having any intention to end their life. However, this did not mean that theywere at a lower suicidal risk because some of the drugs and chemicals (like paraquat) used by these patients can be fatal. Depression resulting from maladjustment to psychosocial stressors was the main cause of attempted suicide in this study. It made up about 59.0% of the total figure and was mainly due to financial problems and interpersonal conflicts with spouses, friends and family members. Only 10.0% of those who attempted suicide in this study had an underlying schizophrenic illness. Most of them were suicidal due to hallucinations; hearing voices telling them to either commit suicide or injure themselves. Most of these patients were seen at least after 24 hours of study in the wards. The majority of the patients were diagnosed as having adjustment disorders, and being in a hospital environment could have further influenced their underlying depression. Furthermore, many of these patients were counselled beforehand by relatives and friends before an interview could be conducted for this study. Therefore, in view of all these factors, it can be explained why two-thirds of these cases had less than 10 points on Pierce’s Intention Scores.
Discussion The findings of this particular study seem to be consistent with findings of other studies done previously in other
Asia-Pacific Journal of Public Health 1992/1993 Vol. 6 No. 2 parts of Malaysia. They also highlight the fact that the high-risk group for attempted suicides in Malaysia seems to be the Indian population, especially in young persons from low socioeconomic groups and females in parti~ula?,~.A comparison of suicidal risks in previous studies could not be made since the cases studied mainly concentrated on the sociodemographic characteristics. The probable reason why more ofthose in the youngeragegroupwere involved in attempted suicides could be that they had to cope with crises at a very vulnerable age. They faced a lot of difficulty in getting new jobs and also with marriage. Many also had interpersonal relationship problems. All these factors could have precipitated a short-term depression that can predispose one to suicidal behavior. In fact, similar findings have also been seen in previous ~ t u d i e s ~ . ~ . Much has been mentioned about the over-representation of the Indian population among those committing and attempting suicide in Malaysia’. Even though no definite cause has been found, it is possible that religious as well as cultural beliefs could be important predisposing factors. Apparently, the Hindu religion, which is the main religion of the Indians in Malaysia, is not definite in prohibiting suicidal behavior’, which is in great contrast to the Islamic religion which is very definite in prohibiting
suicide among its followers. In fact, this could be one of the factors contributing to the low incidence of suicidal behavior among the Malay population not only in Malaysia, but in Singapore as ~ 1 1 ~ . Similar reports of self-poisoning either with prescribed drugs or with other chemical agents have been observed in other studies”. What is apparent is that the type of drugs and chemical agents used were easily accessible, and some could be obtained quite easily from either doctors or p h a r m a c i s t s . T h e r e f o r e , selfpoisoning was used due to the availability of appropriate substances rather than for any other reasons. The low intention scores among many subjects in this study could be due to the nature of the depression that they experienced. They suffered mainly from acute situational reaction or, according to DSM-111, adjustment disorders’ Therefore, the reassurance that patients usually receive after the suicide attempt could have reduced their depression. These factors may also be responsible for the reduction of their intention scores. A low intention scorecan alsomean that many of them attempt suicide as an appeal to get help; what is commonly termed as a “cry for help”. This group ofindividuals had no intention ofkilling themselves but performed the suicidal act merely to get attention from others.
’.
References 1. Vital Statistics, Peninsular Malaysia 1986, Department of Statistics, Malaysia, Kuala Lumpur 1986. 2. Murugesan G, Yeoh OH. Demographic and Psychiatric Aspects of Attempted Suicide. Med J Malaysia 1978;23:102-12. 3. Yeoh OH. Attempted Suicide in Penang. Med J Malaysia 1981;36: 39-46. 4. Klang Valley Planning Secretariat, Prime Minister’s Department, Kuala Lumpur, Malaysia. 5. Pierce DW. Suicidal Intent in SelfInjury. Br J Psychiatry 1977;130: 377-85. 6. Wexler L, Weissman MM, Kasl SV. Suicide Attempts 1970-75: Updating a United States Study and Comparisons with International Trends. BrJ Psychiatry 1978;132:180-5. 7. Tsoi WF. Suicides and Attempted Suicides. Ann Acad Med Singapore 1974;3:125-30. 8. Maniam T. Suicide and Parasuicide in a Hill Resort in Malaysia. Br J Psychiatry 1988;153:222-5. 9. Kua EH, Tsoi WF. Suicide in the Island of Singapore. Acta Psychiatr Scand 1985;71:227-9. 10. Michel K. Suicide Risk Factors: A Comparison of Suicide Attempters with Suicide Completers. Br J Psychiatry 1987;150:78-2. 11. American Psychiatric Association. Diagnosticand Statistical Manualof Mental Disorders, 3rd ed, APA, Washington DC, 1980.
7
Keywords: Attempted suicide, Kuala Lumpur, self-poisoning.
Attempted Suicide in Kuala Lumpur Mohd Hussain Habil MBBS,
T Ganesvaran FRC Psych Eng, DPM LS Agnes MBBS Department of PsychologicalMedicine Faculty of Medicine University of Malaya Introduction
Results
The rate of suicide for Malaysia was about 3.0 per 100,000 for the year 1986’. However, suicidal behavior is not uncommon. Murugesan and Yeoh did a study on attempted suicide in 1981 in The aim of this study is to look into the existing problems amongst the urban population in Kuala Lumpur. The purpose of the study is also to collect sociodemographic data and study clinical features of patients attempting suicide.
The results are shown in Tables 1,2,3 and 4. There were 197 females compared to only 99 males who attempted suicide in this study. The female to male ratiowas therefore2: 1. The majority of cases were below the age of 39 years, and the highest
Material and Methods
Address for reprints: Dr. H Hussain Department of Psychological Medicine, Faculty of hledicinc, University of Malaya, Lcmbah Pantai, 59101) Kuala Lumpur, hfalaysia
The University Hospital is situated in Kuala Lumpur, the capital of Malaysia. The catchment area in the Klang Valley has a population of about 2.5 million which is made up of 46.0% Chinese, 38.5% Malays, 15.0% Indians and 0.5% others. The people are mainly involved in business and administrative jobs4. Patients admitted to the University Hospital after many forms of self-harm were seen by the casualty medical officers and medical officers from the Psychiatric Unit. The authors interviewed the patients within 24 hours of admission to the hospital when their physical and mental state allowed for it. Some of them were interviewed in the surgical and medical wards, while others were seen in the Psychiatric Unit. Patients’ intention for suicide was assessed using Pierce’s Intention Score’. All patients volunteered to cooperate with the invest igations.
Table 1. Sociodemographicdata of 296 patients who attempted suicide Categories
n
%
Male Female
99 197
33.4 66.6
Marital status Single Married Divorced/separated/ wid owed
145 134 17
49.0 45.3 5.7
Age (years) 0-19 20-39 40-59 60 and above
52 197 37 10
17.6 66.5 12.5 3.4
Racial breakdown Indian Chinese Malays Others
142 120 30 4
48.0 40.5 10.1 1.4
37 50 71 41 97
12.5 16.9 24.0 13.9 32.8
No. of persons
Social class I I1 111
IV V
5
Asia-Pacific Journal of Public Health 199211993 Vo!. 6 No. 2 Table 2. .hIethods of self-harm in 296 patients who attempted suicide Method Used
n
%
Self-poisoningalone (n = 251) Drugs Psychotropic Analgesics Other drugs
52 34 24
17.6 11.5 8.1
Chemicals Detergent Insecticide & Pesticide Agrochemicals Other chemicals Multiple drugs and chemical
35 28 22 7 49
11.8 9.5 7.4 2.4 16.6
Physical methods (n = 45) Cutting and stabbing Hanging Ingestion of foreign objects like stones and blades Bums
1s 11 2
6.1 3.7 0.7
2
0.7
Combinations of physical and self-poisoning
12
4.0
Table 3. Diagnosis of 296 patients who attempted suicide Diagnosis Adjustment disorders Alcohol and drug dependence Schizophrenia Affective disorders and grief Physical disorders and complaints Personality disorders Obsessive-compulsive disorder
n
%
176 38
59.5 12.8
30
10.1 258.5 186.1
8
2.7 10.3
proportion was seen in the category who were unmarried. In terms of racial breakdown, it is remarkable that the majority of those who attempted suicide were Indians. This figure could not be explained by racial distribution since the Indian population in the Hang Valley area is the least when compared to the Chinese and Malays. Even though Malays makeup the second major race in the Klang Valley area, the percentage of those who attempted suicide was small when compared to that of Indians and Chinese respectively. Malays only comprised about 10.0% out of the total number of attempted suicide patients in this study.
Table 4. Intention scores of 296 patients who attempted suicide Intention score
Male n (%)
Female n (%)
Total n (%)
0-4 5-9 10-14 15-19 20-25
1g(6.4) 36( 12.2) 25(8.5) 17(5.7) 2(0.6)
5 1( 17.2) gO(30.4) 38( 12.8) 17(5.7) l(0.4)
70(23.6) 126(42.6) 63(21.3) 34(11.4) 3( 1.0)
6
Based on social class distribution, it was apparent that only a small percentage of those belonging to social class I and I1 were admitted for attempted suicide in this hospital. Theyonlycomprised about 29.0% out of the total number of patients studied. This was in sharp contrast to those who were in the lower social class whose numbers were three times more comparatively. The majority of those who attempted suicide in this study preferred to use self-poisoning or ingestion of chemicals as ways to carry out their attempt. This indicates that such chemicals are easily accessible. The majority attempted suicide in an impulsive manner, without even having any intention to end their life. However, this did not mean that theywere at a lower suicidal risk because some of the drugs and chemicals (like paraquat) used by these patients can be fatal. Depression resulting from maladjustment to psychosocial stressors was the main cause of attempted suicide in this study. It made up about 59.0% of the total figure and was mainly due to financial problems and interpersonal conflicts with spouses, friends and family members. Only 10.0% of those who attempted suicide in this study had an underlying schizophrenic illness. Most of them were suicidal due to hallucinations; hearing voices telling them to either commit suicide or injure themselves. Most of these patients were seen at least after 24 hours of study in the wards. The majority of the patients were diagnosed as having adjustment disorders, and being in a hospital environment could have further influenced their underlying depression. Furthermore, many of these patients were counselled beforehand by relatives and friends before an interview could be conducted for this study. Therefore, in view of all these factors, it can be explained why two-thirds of these cases had less than 10 points on Pierce’s Intention Scores.
Discussion The findings of this particular study seem to be consistent with findings of other studies done previously in other
Asia-Pacific Journal of Public Health 1992/1993 Vol. 6 No. 2 parts of Malaysia. They also highlight the fact that the high-risk group for attempted suicides in Malaysia seems to be the Indian population, especially in young persons from low socioeconomic groups and females in parti~ula?,~.A comparison of suicidal risks in previous studies could not be made since the cases studied mainly concentrated on the sociodemographic characteristics. The probable reason why more ofthose in the youngeragegroupwere involved in attempted suicides could be that they had to cope with crises at a very vulnerable age. They faced a lot of difficulty in getting new jobs and also with marriage. Many also had interpersonal relationship problems. All these factors could have precipitated a short-term depression that can predispose one to suicidal behavior. In fact, similar findings have also been seen in previous ~ t u d i e s ~ . ~ . Much has been mentioned about the over-representation of the Indian population among those committing and attempting suicide in Malaysia’. Even though no definite cause has been found, it is possible that religious as well as cultural beliefs could be important predisposing factors. Apparently, the Hindu religion, which is the main religion of the Indians in Malaysia, is not definite in prohibiting suicidal behavior’, which is in great contrast to the Islamic religion which is very definite in prohibiting
suicide among its followers. In fact, this could be one of the factors contributing to the low incidence of suicidal behavior among the Malay population not only in Malaysia, but in Singapore as ~ 1 1 ~ . Similar reports of self-poisoning either with prescribed drugs or with other chemical agents have been observed in other studies”. What is apparent is that the type of drugs and chemical agents used were easily accessible, and some could be obtained quite easily from either doctors or p h a r m a c i s t s . T h e r e f o r e , selfpoisoning was used due to the availability of appropriate substances rather than for any other reasons. The low intention scores among many subjects in this study could be due to the nature of the depression that they experienced. They suffered mainly from acute situational reaction or, according to DSM-111, adjustment disorders’ Therefore, the reassurance that patients usually receive after the suicide attempt could have reduced their depression. These factors may also be responsible for the reduction of their intention scores. A low intention scorecan alsomean that many of them attempt suicide as an appeal to get help; what is commonly termed as a “cry for help”. This group ofindividuals had no intention ofkilling themselves but performed the suicidal act merely to get attention from others.
’.
References 1. Vital Statistics, Peninsular Malaysia 1986, Department of Statistics, Malaysia, Kuala Lumpur 1986. 2. Murugesan G, Yeoh OH. Demographic and Psychiatric Aspects of Attempted Suicide. Med J Malaysia 1978;23:102-12. 3. Yeoh OH. Attempted Suicide in Penang. Med J Malaysia 1981;36: 39-46. 4. Klang Valley Planning Secretariat, Prime Minister’s Department, Kuala Lumpur, Malaysia. 5. Pierce DW. Suicidal Intent in SelfInjury. Br J Psychiatry 1977;130: 377-85. 6. Wexler L, Weissman MM, Kasl SV. Suicide Attempts 1970-75: Updating a United States Study and Comparisons with International Trends. BrJ Psychiatry 1978;132:180-5. 7. Tsoi WF. Suicides and Attempted Suicides. Ann Acad Med Singapore 1974;3:125-30. 8. Maniam T. Suicide and Parasuicide in a Hill Resort in Malaysia. Br J Psychiatry 1988;153:222-5. 9. Kua EH, Tsoi WF. Suicide in the Island of Singapore. Acta Psychiatr Scand 1985;71:227-9. 10. Michel K. Suicide Risk Factors: A Comparison of Suicide Attempters with Suicide Completers. Br J Psychiatry 1987;150:78-2. 11. American Psychiatric Association. Diagnosticand Statistical Manualof Mental Disorders, 3rd ed, APA, Washington DC, 1980.
7
