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 outcome1

• Suicide methods include:– Drug overdose, poisoning– Hanging, Drowning– Gunshot– Jumping from heights, onto or from running vehicles

1Gelder, M., Harrison, P., & Cowen, P. (2006). Shorter Oxford Textbook of Psychiatry.(5th 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 seconds2

In Malawi: 2,269 deaths (1.09% of total deaths) Aged adjusted death rate is 23.32 per 100,000 of

population ranks Malawi #6 in the world3

Suicide is #16 as cause of death in Malawi

3WHO (2011). Malawi: Suicide. Accessed on April 15, 2013. Available on http://www.worldlifeexpectancy.com/malawi-suicide

2World Health Organization: Suicide Prevention. Accessed on April 17, 2013. Available on http://www.who.int/mental_health/prvention/suicideprevent/en/index.html

Laws in individual jurisdictions

• Malawi, Kenya, Nigeria, Rwanda, Tanzania, Ghana and Uganda are among other African countries that currently criminalize nonfatal suicidal behavior5

• In Malawi, suicide attempters have been convicted and sentenced to several months or years of imprisonment with hard labour

5Kanjo, M. (2011, February 25). Why is suicide a crime? Retrieved from http://www.nationmw.net/index.php?option=com_content&;view=artikel&id=15100:why-is-suicide-acrime&catid=236:think

Laws in individual jurisdictions

In Zambia6, Zimbabwe7, UK and Wales8, suicide is not a crime

The laws of these countries are against inciting and assisting suicide

6Suicide Act, 1967 of Zambia7Criminal Law Code, 2004 of Zimbabwe8Suicide Act, 1961 of England and Wales

Link between Suicide and Mental illness

• Suicide is a multidimensional disorder9

• Between 40% - 60% of people who commit suicide saw physician in the month prior to suicide

• Overall prevalence of mental disorders is 80-100% 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%

9WHO (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 events10,11

10Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.11Joiner, 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 criteriaAge; 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: 36.93 yrs (SD 19.405) 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 stressorsRelationship problemsPoverty related Chronic physical illness, Chronic psychiatric illness, Positive

HIV statusExcessive alcohol useFearing to be arrestedUnknown 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 registry12

• Central Suicide registry is important for a country in order to understand burden and develop proactive strategies

12Adinkrah, M. (2011). Epidemiologic characteristics of suicidal behavior in contemporary Ghana. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 32, 31-36.

Discussions• Motivation or stressors for suicide in this review

are consistent with several studies11,10,14

• Findings of suicide methods are different to hospital-based study which revealed pesticide poisoning, 66 cases out of 84 (79%) and self immolation13

13Dzamalala, C. P., Milner, D. A., & Liomba, N. G. (2006). Suicide in Blantyre, Malawi (2000-2003). Journal of Clinical Forensic Medicine, 13 (2):65-69

14Adinkrah, M. (2012). Criminal Prosecution of Suicide Attempt Survivors in Ghana. International Journal of Offender Therapy and Comparative Criminology. Accessed on April 17, 2013. Available on http://ijo.sagepub.com/content/early/2012/08/21/0306624X12456986

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 MalawiPsychological autopsiesEpidemiological studies

Revise current pathway to care

Food for thought

Is decriminalization or depenalization of suicide important in

Malawi?