Indonesia - Why artists die young: A tale of suicide and mental health

Every year, nearly 800,000 people commit suicide. Suicide was the fifth leading cause of death among those aged 30 to 49 in 2012, globally, and the second in the 15 to 29 age group. The International Association for Suicide Prevention (IASP) and the World Health Organization (WHO) are committed to preventing suicide.

Suicide is complex because it has no single cause. Suicide is most of the times caused by a combination of many different factors, such as psychiatric disorders, social pressure, psychological trauma, biological factors, genetic factors and physical disorders.

Data from psychological autopsies carried out in 1999 showed that mental illness was among the major factors for suicide with more than 90 percent of suicide cases accompanied by mental disorders. Based on data from the Indonesia Health Research (Riskesdas) in 2013, the prevalence of severe mental disorders (psychosis or schizophrenia) in Indonesia's population was 1.7 per 1,000 people. The prevalence of mental emotional disorder in the population aged 15 and above was 6 percent.

Previous research shows that artists were more susceptible to committing suicide than other population groups because of the ostensible prevalence of mental disorder in artistic people. Two contemporary painters, S (1973-2003) and A (1975-2005), both decided to end their lives by hanging themselves in 2003 and 2005, respectively.

This is my story of performing a psychological autopsy of the two deceased painters.

Coming to Yogyakarta

I tried to locate S’s and A’s paintings in Yogyakarta and a curator introduced me to their family members and fellow painters.

I managed to find the locations of the deceased painters’ rented houses. One of the painters committed suicide in a rented house in Yogyakarta while the other did it in his parents’ house in Magelang, Central Java. There was a similarity to both houses: quiet and isolated, providing an opportunity for a painter to seek ideas, think, and reflect.

Both painters hung themselves at the age of 30, still considered within the young adulthood group, according to Erik Erikson’s psychosocial development category. At this stage, people share themselves more intimately by exploring relationship toward long-term commitments with someone other than family. Successful completion of this stage can lead to comfortable relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression.

Back in Jakarta: Psychological autopsy

In my psychological autopsy on photos of the paintings by the deceased painters and the interviews with family members and fellow painters, I found streaks of psychopathology appearing. 

S’s psychopathology began to appear with a change in behavior beginning 2001. He complained of hearing voices that he felt as an attack against himself (auditory hallucinations). He felt that he was being harmed by black magic and persecuted by those devilish people (persecutory delusion). Approaching his death, he felt his hands were rotting and ravaged by maggots (bizarre delusion). Affective components can be seen from the great energy he had in painting various paintings of great size, day and night without stopping, and sadness towards suicide. Meanwhile, A experienced dominant psychotic symptoms, such as auditory hallucinations, delusion of being controlled, and persecutory delusion. There were somatic symptoms and sadness toward the end of his life. Family witnessed him cry and lose interest in painting.

Protective factors did not prevent them from committing suicide. S showed social withdrawal prior to suicide. He also came home and showed worsened psychopathology, but the family did not take him for psychiatric treatment. A turned to religion but was misguided by a spiritual healer. Both had precipitating factors: S got dumped by his girlfriend, while A became increasingly desperate with his illness and showed warning signs by saying he wished to die and bought rope at the nearest warung. He even came back to look for a longer rope.

Family history also plays a major role. S had no family history of suicide or substance abuse. Neither did A, but A’s brother showed signs of psychopathology in auditory hallucination.

An expert, Dr. Eugen Koh, who is a psychiatrist from the art psychiatry unit of St. Vincent's Mental Hospital, director of the Dax Collection and Anthony White Lecturer in art history at the University of Melbourne, has also helped me analyze the paintings.

Koh analyzed the photographs of the paintings I sent through e-mail and came up with possible differential diagnoses. A definite diagnosis was not possible because the deceased painters did not undergo psychiatric interviews. 

Koh’s Differential diagnosis on S:

Possible schizophrenia and schizoaffective with narcissistic personality traits. Narcissistic Personality Disorder tends to use the defense of mania. There seems to be an impression of mania (visible from the habit of painting the whole night while singing) in the early stages of his psychosis.

Koh’s Differential Diagnosis on A:

Possible schizophrenia or anxiety neurosis with episodes of depression with obsessional personality.

Are these differential diagnoses stigmatizing their suicide? No. These diagnoses are evidence that mental illness should have been treated like any other disease before it leads to suicide.

I conducted my research in 2008, until now, no further research has been done on this psychological autopsy level. 

Stigma often inhibits the reporting of suicide cases so that not all cases are reported. In many countries, suicide cases are underreported. The World Health Organization (WHO) and the UN recommend all governments to have a national suicide prevention program linked to related public health policies.

Screening mental illness in vulnerable groups is a form of suicide prevention. Connection is crucial to individuals who may be vulnerable to suicide. World Suicide Prevention Day sponsored by the IASP that fell on Sept. 10, promotes the theme "Connect. Communicate. Care." And the media—according to the 2014 Mental Health Law, has a role to play in socializing the importance of being aware and taking part in suicide prevention in a way that is conducive to the growth and development of mental health.

Nova Riyanti Yusuf

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You can find older posts regarding ASEAN politics and economics news at SBC blog, and older posts regarding health and healthcare at IIMS blog. I thank you.

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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You can find older posts regarding ASEAN politics and economics news at SBC blog, and older posts regarding health and healthcare at IIMS blog. I thank you.

Lao - Lao Farmers Still Use Dangerous Herbicide Despite Ban

Farmers in the northern Lao province of Xiangkhouang are using so much of the herbicide paraquat on their crops that questions have been raised about the impact of the chemical on the environment and the government’s ability to control its use, RFA’s Lao service has learned.

Despite a two-year-old ban on the chemical in Xiangkhouang, farmers can easily buy paraquat, and are using about 25 times the amount recommended by the manufacturer, according to an official with a civil society organization.

“The amount of herbicide use is high, 80 liters per hectare, which is overuse,” said the civil society official who spoke on condition of anonymity. “The standard use is only three liters per hectare,”

A Lao agriculture official told RFA that authorities are aware of the problem, but are struggling to bring it under control. The official told RFA that the abuse of paraquat is depleting nutrients in the soil, but that it is up to local authorities to curb its use.

“Provincial authorities have banned this substance for two years,” an agriculture official in Nong-het district told RFA. “The agriculture sectors are in charge of controlling it, but it is still smuggled in for sale in the province.”

When contacted by RFA, Khamphou Chanthavong, director general of Xiangkhouang province’s natural resources and environment department, refused to comment on the issue.

While the herbicide is banned in Xiangkhouang, farmers there have become so accustomed to using it that they cannot kick the paraquat habit, sources tell RFA.

“It is difficult for farmers to stop using paraquat for their maize plantations because they have gotten used to it,” the civil society official told RFA.

Farmers in Xiangkhouang’s Nong Het district have been using paraquat since 2008, when they were trained on intensive agricultural production, a Lao agriculture official told RFA.

Paraquat is one of the most widely used herbicides in the world, and while its toxicity is low when sprayed in recommended doses, it poses serious health issues to anyone who handles the chemical.

A small, undiluted dose can kill a human, and paraquat is blamed for a large number of pesticide-related deaths. It is a major suicide agent in many developing countries, and in 2011, the U.S. National Institutes of Health found a link between paraquat use and Parkinson's disease in farm workers.

While paraquat has dangerous side effects, it also has benefits. When used properly it kills weeds without the need to plow them under and it is less reactive in the environment than other herbicides.

Xiangkhouang officials decided the dangers outweighed the benefits and banned the chemical, but they admitted they were unable to control its use.

“Authorities banned the use, but farmers cannot stop using it because they have gotten used to it for many years,” said the Lao agriculture official.

Reported by RFA's Lao Service. Translated by Ounkeo Souksavanh. Written in English by Brooks Boliek.

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