While suicide rates in general have reduced due to various interventions by the Health Ministry, the number of attempted suicides have risen prompting health officials to take a fresh look at this disturbing emerging problem. Added to their concerns is the fact that the number of maternal suicides are also on the rise .When a mother dies prematurely the fall out on her immediate family , including her children are often horrific.
Studies conducted elsewhere have shown that most mothers are vulnerable to suicidal tendencies, especially, if they already have pre-existing conditions such as, psychotic disorders, heart, liver and depression. Limited studies have also shown that in Sri Lanka most children who have lost their mothers have been abandoned by their fathers or other carers and left to fend for themselves, exposing them to physical and mental abuse.
The Sunday Observer spoke to Consultant Psychiatrist, and former Director National Institute of Mental Health, Angoda, Dr Jayan Mendis to give us some new perspectives on this hitherto little understood and studied issue in Sri Lanka.
Excerpts…
Q..As you know, Sri Lanka is one of the countries where we have a high suicide rate. Our suicide rate was the highest in the world in 1995. However, with various actions we could manage to reduce our suicide rate up to 25/100000. Not like suicide rate, 30% of maternal deaths in Sri Lanka are due to suicides, and VOGs and other health staff have worked very hard throughout the country to reduce the maternal mortality rate from 500 per 100000 in 1950 to about 12 per 100000 in 2010. Of this, maternal suicides and cardiac deaths comprise a great part. Out of these cardiac deaths most of the deaths have been due to structural heart disease in which the cardiologists do not have a major role to play. However, if the psychiatrists and VOGs join hands with the Health Ministry, I believe most of the suicides could be prevented. That’s the reason why I was inspired to discuss maternal suicide at a recent seminar on suicide prevention.
A. When the Task Force on suicide prevention was set up in 1996, its main concern was to reduce suicide in general, which was a burning issue at the time. Sri Lanka had very basic mental health facilities during that time. But, after introducing the Task Force proposals we were better able to counter suicides in general and maternal suicides in particular. Q. Were the rates of maternal suicides high even then?
A. No. Maternal suicide rates were not that high during that period.
Q. What about the rate of maternal deaths due to suicide today? Are they higher than in the past?
A. When you compare the incidence of maternal deaths in the past years, today, maternal deaths due to suicide comprise a huge chunk in our records.
Q. Are suicide rates in general comparable to the rates in other countries, including developed countries in the West?
A. Yes, our suicide rate is still high when compared to other countries in the world. In developed countries such as Australia 12.6 per 100000 in 2015, USA 13 per 100000 and UK 11 per 100000.
Q. What are the current suicide rates in Sri Lanka gender wise and age wise?
A. Male to female suicide rate in Sri Lanka were earlier in a range of 2.5 to 3.5. At present, it is 2.6 male suicides per one female suicide. Male attempts are usually more successful, especially, in the case of older males. While younger females also die by suicide, their female percentage is lower.
Q. What contributes to this discrepancy in male/female suicides according to their age?
A. Alcohol plays a major role in male suicide. Males also use more lethal methods of suicide than females.
Q. Does pesticide availability, especially, in farming communities where suicide rates are very high also pose a significant risk for suicides?
A. Earlier, a large number of people committed suicide (deliberate self harm). However, when toxicity levels of pesticides imported to the country were reduced, the number of attempted suicides increased. People also began choosing other methods e.g.. moving from pesticide to medicinal drugs. Fortunately, we now have better emergency facilities to deal with the problem, such as, admitting patient to hospital via ambulances and even trishaws. As a result, the number of suicides came down and the number of attempted suicides have gone up. Yes, pesticide was cited as the leading method used in suicide in 1990. But, as I mentioned, the methods of suicide have changed- from hanging to more overdose of pharmaceuticals. However, we have informed the Director General of Health Services to request the President to appoint a similar Task Force to look for more solutions to prevent suicide in the coming years.
Q. To return to our main topic, what causes a mother to take her own life before and after giving birth to a child she has carried within her womb for nine months? Is this an emerging risk in Sri Lanka?
A. As you know, in Sri Lanka a lot of people who try to take their own life really do not want to die. It is an indication for us to understand that they require some help. Coming to your question, there are many reasons for a mother to want to commit suicide. Maternal depression is one reason.
If maternal depression is not properly treated or detected early or for some reason it had been unable to identify it as a psychological problem , the mother could end up committing or attempting to commit suicide.
Q. Are there other factors that trigger this impulse in mothers?
A. Causes other than depression and puerperal psychosis could be family conflicts which mothers could not cope with . Even though we have not done studies on this, in UK, about 80% of maternal suicide has a relationship to various psychological disorders.
Q. Can a mother who never had a psychotic problem develop a psychological problem during pregnancy or after?
A. Usually, new psychiatric disorders would not emerge during pregnancy. However, those who have psychiatric disorders are more prone to relapse during pregnancy. Some percentage of that cohort ends up in suicide if not treated early. But, after the birth of the baby, the mother is more vulnerable to psychiatric disorders due to the delivery of the baby.
Q. Why?
A. Causes are multifactorial. Usually, due to more than physiological changes happening after delivery, changes of psychological factors leading to development of these disorders.
Q. How do you classify maternal deaths? At what stage before and after pregnancy is a mother most vulnerable to the risk of suicide?
A. Maternal deaths are classified as Direct e.g. bleeding after delivery (haemorrhage ) and Indirect e.g. pre existing conditions or illnesses pertaining to heart, liver, kidney etc or coincidental e.g. accidents. Usually, maternal deaths count from 24 weeks of gestation to 42 days after delivery called early maternal deaths and 42 days to 365 days called late maternal deaths. For calculation purposes, deaths occurring up to the first year after delivery are called maternal deaths. All these deaths are preventable. We need to look into this disturbing trend and take necessary action to prevent it happening.
Q. Considering the rising rate of mothers experiencing psychotic depression leading to depression and suicides among mothers, have you considered the risks that their babies are exposed to, as well ?
A. One in a thousand mothers with deliveries will experience post psychotic depression. Even depression of mothers with postpartum neglected psychosis will lead to suicide. And yes, some of them may try to harm their babies before they commit suicide.
Q. Tell us in detail the different reasons that lead mothers to take that desperate decision to end their lives?
A. Usually, when a woman becomes pregnant she initially experiences some kind of changes in her body to which she must adjust. However, a small percentage of women are unable to adjust to their pregnancy effectively.
Some others may continue to have morning sickness which is also linked and has a relationship with their psychological well being. Still others may experience difficulties in their interpersonal relationships, especially, with their husbands. Having unsupportive alcoholic and violent relationships with their male partners could aggravate the mental health problems for those who have a pre existing psychiatric disorder. So, this is a problem that needs to be identified early by the attending physician.
Q. Signs to look for?
A. Some mothers show early signs of depression during pregnancy. Those who have had malformed pregnancies are more prone to become depressed.
After delivery when a mother is showing features of aggression, irritability, poor sleep, having difficulty in feeding, or suffer from delusions such as seeing her well formed baby as a deformed baby, are the early signs that the mother is showing features to suggest that her psychological well being is not good.
Q. Let’s discuss some of the gaps that need to be filled in this area. Firstly, do you have enough psychiatrists country wide able to cater to the growing number of people attempting suicide, along with the fact that we have an aging population who are also prone to depression?
A. There are sufficient numbers of psychiatrists working in the country. However, 100 more psychiatrists are being trained and they will commence to work within the next 5 years. However, there is a shortage of psychologists attached to the Health Ministry.
Q. What about trained counsellors, especially, at grassroots level, which is the first point of contact for mothers in rural areas?
A. In some of the universities and some private organizations, the training of counsellors who may be working in the grassroots level is not very satisfactory. There is room for improvement and is a matter to be looked into.
Q. Your advice to the public ?
A. Mental health problems need to be detected early. The early the treatment, better the response. If detection is late then response to treatment will also be poor. You need to have a fair degree of understanding about a person to detect a mental illness.
If there is any suspicion of a mother or any other person having a mental problem, bring that person for psychiatric assessment as soon as possible, to any of our many clinics around the country.