Profile differences between overdose and non-overdose suicide attempts in a multi-ethnic Asian society

Suicidal behaviour is a global public health concern that leads to not only an immense financial burden on society, but also incurs a hefty psychological toll on survivors and their loved ones. Each year, 10–20 million individuals attempt suicide and over 800,000 lives are lost [1]. Despite the fact that Asian countries account for about 60 % of global suicides [2], there is inadequate resources to tackle the magnitude of the problem in this region. This is compounded by the lack of reliable statistics and rigourous suicide research. While extant literature has data on epidemiologic characteristics and trends of suicide methods common in Asia [3], the gaps in knowledge on the influence of various characteristics and risk factors on different suicide methods persist. Suicide methods have been found to be particularly influenced by the availability, knowledge, past experiences, symbolism, cultural significance, and mental state of the attempters [4]. The psychosocial needs of suicidal individuals could also contribute to the chosen method of suicide [5]. Differences in methods may lead to different outcomes such as repetitive suicide attempts or eventual suicide completion [6, 7], which have differing implications on the regional health system and financial costs. Modification of the environment by restricting access to lethal means such as firearms, pesticides and charcoal burning have been found to reduce method-specific suicide rates, and when the method is prevalent, it could lead to decline in the overall suicide rate [8]. Nevertheless, there have also been other studies that suggested restriction of certain means might not effectively reduce suicide risk as it might prompt suicidal individuals to consider alternative means of suicide, which potentially could be more fatal [9]. Therefore, it is imperative that a greater emphasis be placed on understanding the intricacies of suicidal behaviour in Asia by elucidating the suicide characteristics of each country and culture. The World Health Organisation (WHO) recommends the enhancement of suicide prevention efforts by improving the availability and quality of data from hospital-based systems [10]. The knowledge acquired from such data will play a pivotal role in the formulation and implementation of targeted suicide prevention measures.

Singapore which is ranked 97^th in the world in terms of number of suicide deaths [11], is a culturally diverse society (Chinese: 74.3 %, Malay: 13.3 %, Indian: 9.1 %, Others: 3.2 %) in Southeast Asia [12]. The most common methods of suicide in Singapore include jumping from height, hanging, and poisoning [13]. Most studies of suicide in Singapore are based on data obtained from the Registry of Birth and Death, and from Coroner’s Court reports [14, 15] and few studies have analysed the data from hospitals. As part of standard operating procedures in the hospital systems of Singapore, a patient admitted following his or her suicide attempt is required to undergo psychiatric assessment. Data from such assessment holds valuable information such as socio-demographics and characteristics of suicide attempters that can guide future policies and protocols in suicide prevention. The study was therefore conducted to compare and contrast the profiles of suicide attempters. As jumping from height and hanging are more likely than poisoning to lead to suicide completion and thereby resulting in the lack of data of interest, we classified the attempters into overdose (OD) and non-overdose (NOD) groups for comparison. In this study, people who took medication at higher doses beyond what was recommended by doctors with an intention to commit suicide were labeled under the OD group. As there have been few studies comparing the suicide profile of people who overdosed on drugs compared to those who used other methods, this would be a pertinent area of study. With variation in the nature, circumstances and lethality of suicide method between OD and NOD groups, we hypothesised that there would be differences in socio-demographics, suicide characteristics, as well as risk and protective factors between the two groups. The present study also serves as an update to a previous study done between 2004 to 2006 [16] and explores the differences in characteristics between OD and NOD attempters in Singapore.

Due to the changes in patient risk factors over time, it is important to keep abreast of the characteristics of current suicide attempts, so as to guide the government in developing up-to-date strategies for the prevention of future suicide attempts [39]. Information generated from our study would be an important addition to the current knowledge pool on suicide and contribute to the subsequent development of new treatment methods [14] and may also validate the efficacy of current treatment methods [40, 41].

In a recent study conducted by Chong et al. [42], majority of Singaporeans (68.3 %) who were suffering from mental disorders failed to seek help, and 55.6 % of individuals thought that they could handle the problem on their own, while 31.6 % were oblivious of their mental condition. This, together with the data from our study, hints at the importance of encouraging individuals to have greater awareness of mental health issues, and increasing the platforms of help available (e.g. suicide or crisis hotlines) through use of new media such as the social media and smartphone applications. Additionally, policymakers and mental healthcare providers should evaluate and improve on current protocols in identifying and supporting psychiatric patients with suicidal ideation. Since repeated psychiatric admission is predictive of an eventual completed suicide via the OD method, standard care in a psychiatric healthcare setting may have to include more timely follow-up sessions and changes in drug prescription for patients who fall into this category. Finally, public education and outreach programs in the community can empower individuals with the relevant knowledge of identification of suicidal behaviours and signs of deliberate self-harm in their peers and loved ones.

In view of the significant number of suicide attempts being committed at home, another potential suicide prevention strategy would be to foster greater social support among the community. Since individuals who live alone are more prone to repetition of acts of deliberate self-harm [43], closer relationships with neighbours will promote social inclusion and reduce the possibility of repeated suicide attempts. In addition, regional health systems can also improve its accessibility to people at risk of suicide, thereby lowering the barriers to self-reporting of suicide attempts. This may include setting up of more social service centres near densely populated areas to increase accessibility to social resources, and ensuring integration of care between these service centres and other healthcare services.

Future research in the direction of teasing out the factors that motivate people of different ethnicities to choose different methods of suicide, and other risk and protective factors that mediate and moderate OD and NOD suicide attempts, will allow for a more complete understanding of suicide in the Asian context.