Indonesia - Suicide: The scream of unspoken pain

Pop quiz! Guess how many suicides happened all over the globe yesterday?

You see it in newspapers, on television and your social media timeline. Every single day, new suicides pop up with a variety of victims, methods and motives. Suicide happens all over the world and occurs in all age groups. To answer the question above, it is estimated that around 2,200 people died in suicides yesterday.

The World Health Organization (WHO) estimates 800,000 people die due to suicide each year worldwide, or one death every 40 seconds. That’s right, by the end of this paragraph, one soul has been lost due to suicide.

The number of suicides is increasing and it is forecast that by 2020 the rate will have climbed to one every 20 seconds.

The American Foundation of Suicide Prevention stated that for every suicide there were 25 failed attempts. This makes suicide one of the leading causes of death and a heavy burden for communities. WHO states that, in 2012, suicide was the second leading cause of death among 15-29 year olds, golden years for activity and productivity.

Who is to blame?

As doctors engaged in mental health, we deal a lot with people who deliberately self-harm, whether they are suicidal or not. From our daily experience, we find that most people tend to blame the victims themselves. They consider people with a history of suicide attempts as “people with weak faith”, “spoiled”, or even “narrow-minded”.

People closest to the victims are often the ones who accuse them of “making the wrong choice”. But do they really have a choice? Do they even have the capacity to consider such choices?

There’s a reason why suicide and self-harm is a significant finding in mental health evaluations. Psychologically speaking, humans have an instinct to stay alive. Sigmund Freud coined the term life instinct: “the instinct essential for sustaining the life of the individual, as well as the continuation of the species”.

Included in life instinct are basic survival and pain avoidance. Therefore, suicide and self-harm seem counter-intuitive.

In fact, people with suicidal ideations and those who self-harm often have coexisting mental disorders, such as major depression, bipolar disorder, panic disorder, personality disorder, or schizophrenia.  In those cases, self-harm may be a scream of unspoken emotional pain.

Experts estimate that up to 90 percent of people who commit suicide have diagnosable mental disorders. There are two things to consider here: 1) the majority of people with mental disorders are at risk of self-harm or suicide; 2) this number may just be the tip of the iceberg.

Are we stigmatizing people who self-harm?

WHO estimates there are around 30,000 suicide deaths annually in Indonesia, which means approximately 82 lives are lost every day due to suicide, mostly by poisoning or hanging.

How do we react to this phenomenon? Let’s take a look at BPJS, Indonesia’s national health insurance. BPJS officially states that “health disorders due to deliberate self harm” are not covered in its policy. As a consequence, there is chance that a doctor prefers not to write “suicide attempt” in the patient’s medical record. In the long run, we may never know the exact number of suicides in Indonesia.

Just tell them that you want to understand their pain. Tell them that you will be there when they need someone.

It is ironic that while we are aggressively delivering a campaign on mental health awareness, our national health insurance ignores one of the main symptoms of mental disorder. BPJS should renew its policy to include self-harm and suicide attempts. This would be harmonious with its current support for mental health services.

September is Suicide Prevention Awareness Month. This month is dedicated to promoting public awareness about suicide prevention. Basically, we want everyone to be able to help and talk about suicide without increasing the risk of harm.

Here are four reminders related to suicide prevention:

1. Suicidal thoughts can affect anyone regardless of age, gender and socioeconomic level. Theoretically, everyone is at risk. Therefore, do not ever think “no, that guy will never commit suicide, I know him too well”.

2. Every suicide threat is real. Do not automatically consider it as attention-seeking behavior. Threats or comments about killing oneself can begin with mild, harmless thoughts like “I wish I wasn’t here”, which later evolve into something bold and dangerous. The threat can be spoken, written or seen as behavioral changes or social withdrawal.

3. If you don’t know what to say, you don’t have to say anything. Just listen.

Most people with suicidal ideation have received countless pieces of life advice and that may be the last thing they need on their current to-do list. Your good-natured advice may be perceived as just more “people-do-not-understand-me” advice.

Just tell them that you want to understand their pain. Tell them that you will be there when they need someone. Giving random advice, such as reminders of their family or religion, may just exacerbate their suffering. 

4. Encourage them to see a psychiatrist. Tell them that you want to help and make them feel better. Find information about nearby psychiatrists or mental health services, and help them make an appointment and accompany them.

Taking someone to a psychiatrist for the very first time is similar to taking a child for immunizations. You may expect resistance at first. But it is definitely an attempt to increase the person’s quality of life.

Andreas Kurniawan

The writer is psychiatry resident at the School of Medicine, University of Indonesia, Jakarta.

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