SUICIDE IN THE PHILIPPINES: A SECOND LOOK AT RATES AND RATIOS

by Dinah Pacquing- Nadera M.D., M.Sc.[1]



Introduction

The Philippines is cited to have one of the lowest male (2.5) and female suicide rates (1.7 per 100,000) in the Western Pacific Region[2]. Many attribute this data to the Filipinos’ grounding in the Catholic faith, natural resiliency, and gregariousness as a people and as a nation. “Connectedness” as being preventive for suicide is a concept that needs no proof in the Philippines. Filipinos are known for close family ties, extended family structure, and a nation of connections, the Philippines being called the texting (SMS) capital of the world.

There is, however, a general perception of an increasing trend in suicide rate recently based on suicide reports not from hospital records but from print and broadcast media. Such growing awareness alerts public health workers to consider it a problem. However, the said “perceived increase” requires a burden of proof to aforementioned “actual data.”

The overall purpose of this paper is to take an objective look at suicide reporting in different settings and draw implications to what Philippine suicide trends may be. Specifically, it presents some suicide data gathered from different studies in the Philippines. It also tracks down actual reporting process of suicide in a medico-legal setting, examines media reporting, and an analyzes the process through which suicide figures seem to get lost in hospital statistics.

Currently, there is no suicide prevention program in Philippines. Major barriers to the development/implementation of national suicide prevention plan include 1) lack of factual data to cite magnitude of the problem, hence, lack of evidence to support need and fund for program; 2) competing interests within the Health System where budget is limited; and 3) strong Catholic faith which frowns upon suicide discouraging families from reporting.

This descriptive study, which is a situationer on suicide reporting in the Philippines, will hopefully shed light into a practical approach to generate the much- needed reliable data to establish a national suicide rate. In addition, this will enable more appropriate interpretation of current suicide data. In the end, availability of factual data to cite the real magnitude of the problem may entice the necessary support needed for a national suicide prevention plan.

Suicide Research Data

Local data on suicide in different settings were reviewed: mental hospital, general hospital, police reports, school and community.

An unpublished paper by Jularbal (1994)[3] presented a review of suicide cases among in-patients at the National Center for Mental Health during a period of 10 years. During this period, there were 17 suicidal deaths in a hospital whose average number daily in-patient was 3,700. Hospital records of 11 of the suicides were reviewed.

The most vulnerable age group was between 20-29 years old, mostly single males, unemployed, and most had some years in high school. A majority of the patients were diagnosed to have Chronic Schizophrenia, Unspecified Type. Majority of the suicides manifested depressed, anxious, withdrawn, and agitated behavior prior to their committing suicide. Most of the suicidal deaths occurred during the months of July (23.5%) and May (17.6%), and usually during the night shift between 11 pm and 7 am.

Data from a private university general hospital (1986)[4] showed a predominance of females admitted at the emergency room for self-harm. The most common methods of inflicting self-harm were overdose (isoniazid, paracetamol, and pesticides), shooting, jumping and hanging. Although there were more female admissions, mortality was higher among males.

In the Philippines, suicide has been a medico-legal more than a health issue. Morales (1979)[5] reviewed 30 cases of completed suicide among adolescents in three Metro Manila cities from 1972-1977 police records. Two thirds (67%) were between 18-21 years old. Most have indicated intentions of committing the act or showed signs of psychiatric disorders. Personal crises due to a threatened loss or separation of any kind and private hopelessness were cited as the paramount motives for suicide. Methods of committing suicide included shooting oneself (40%); hanging (30%); poisoning (16.7%); and jumping from high places (13.3%). In 73% of the reported cases, suicide was committed in their own homes.

The 2003 Philippine Global school based health survey (2003)[6] conducted in 10 countries (including the Philippines) surveyed students 7,338 students in the 2nd, 3rd, and 4th years of high school between the ages 13 to 15 years. The survey measured alcohol and other drug use; unintentional injuries and violence; hygiene; dietary behaviors and overweight; physical activity; tobacco use; mental health; and protective factors. Results of the data analysis on selected mental health indicators were as follows:


Table 1. Percentage distribution of selected mental health indicators
among high school students, 13-15 years old , Philippines


Males
Females
Both sexes
Felt lonely most of the time or always during the past 12 months
9.8 ± 1.4
9.5 ± 1.7
9.9 ± 2.0
Seriously considered attempting suicide
16.1 ± 2.7
17.4 ± 3.7
15.3 ± 2.6
Have no close friends
2.9 ± 0.8
3.3 ± 1.2
2.6 ± 0.9
Source: 2003 Philippine School-based Global Health Survey


The above data shows that even among adolescents who are considered to be in a “regular” environment are at risk of committing suicide.

At a larger population base, Mcdonald (2003)[7] documented ands analyzed a unique suicide phenomenon observed over a period of 20 years in a small population of tribal inhabitants of Kulbi, Southern Palawan, The yearly established was one of the highest in the world (136 per 100,000 between 1990 and 2000, and 173 between 1990 and 2001). The rates are second only to the Aguaruna of Peru (180 per 100,000).
Macdonald grouped the suicides into "melancholy suicides" (common among older people), "gender relations suicides," "passionate and angry suicides," "multiple suicides out of grief" (a chain of suicides, or cluster suicides) and "impulsive suicides of teenagers." Generating a theory for such staggering figures, Macdonald concludes, as far as the population is concerned that:
“1. Current views hold that suicides are the result of stress and emotional pressure combined with conscious, rational, albeit faulty, thinking; and

2. Suicide is not conceivably committed with fear or hope based on local eschatology, nor with a notion of supernatural sanction, positive or negative. It is just consistent with the inherent secular nature of this society that the only cultural model offered is a judicial one, not a religious one. Suicide is framed in terms of social behavior and law. The anthropological model called for should then be premised on concepts inherent to customary one.”[8]

With the above local data in pockets of diverse population in the country, what can now be said about Philippine suicide rates? In a WHO document on reporting suicide in general, one is guided into considering specific issues that need to be addressed when reporting on suicide:[9]

1. Statistics should be interpreted carefully and correctly;
2. Authentic and reliable sources should be used;
3. Impromptu comments should be handled carefully in spite of time pressures;
4. Generalizations based on small figures require particular attention, and expressions such as “suicide epidemic” or “the place with the highest suicide rate in the world” should be avoided;
5. Reporting suicidal behaviour as an understandable response to social or cultural changes or degradation should be resisted.


Table 2. Suicide Rates (per 100,000), by country, year, and gender.
Most recent year available, as of May 2003 (WHO)

Rank
Country
Year
Males
Females
1
LITHUANIA
00
75.6
16.1
10
SRI LANKA
91
44.6
16.8
20
POLAND
00
25.9
4.9
30
ROMANIA
01
20.8
3.9
40
UNITED STATES OF AMERICA
99
17.6
4.1
50
SINGAPORE
00
12.5
6.4
60
EL SALVADOR
93
10.4
5.5
70
BRAZIL
95
6.6
1.8
80
TAJIKISTAN
99
4.2
1.6
83
PHILIPPINES
93
2.5
1.7
90
JAMAICA
85
0.5
0.2
100
SAINT VINCENT AND THE GRENADINES
86
0.0
0.0



Revisiting the published suicide rates for the Philippines, it is noted that the figure dates back to 1993. The overall suicide rate of 2.1 ranks a low 83 of 100 countries. In many recent reports and press releases, this figure is consistently cited. It is unfortunate that current reliable data for a national suicide rate is not available.

Suicide data can however be generated from emergency wards ( for poisoning and other suicide attempts), in-patient settings, and the Police Department since suicide reports are considered as medico-legal cases.

Suicide Reporting Process

In order to track down suicide reporting process, a key informant interview with a staff of the Homicide Division of the Manila City Police Office was conducted. Suicide reporting process elicited from the interview is shown in Figure 1.

In the event of sudden and/or unexplained death of a person at home, in a building, public place, or a hotel, the person who discovers the death may report the incident to the Homicide Division of the Police Department , bring the body to the hospital for declaration of death, or to the morgue/funeral parlor. Any report to the Homicide Division will be investigated and a Spot Report will be accomplished and posted in a bulletin board that is accessible to media. This explains how news on suicide, murder, or accidents is reported on the news, either broadcast or print. The Spot Report contains information on the nature of the case, identification of a victim, suspect over the death, date, time and place of the incident, facts of the case, and recommendation.

The investigation of the case and the final statement of the possible crime surrounding the death rests upon the Criminal investigation and Detection Unit of the City Police Office. In most cases, sudden and/or unexplained death is classified under the category “Death Under Inquiry”. This category includes foul play, suicide, natural death, or any undetermined death. Although suicide is strongly suspected when there is a witness to its commission, previous history of suicide, suicide notes or verbalizations of it, the classification of “suicide” still does not appear in the police records. Suicide statistics based on homicide reports, to be established, requires one to go through spot reports and follow-up cases that seem to be suicide incidents. An annotation stating “probably suicide may appear in some Spot Reports though. However, it has been more of a practice not to indicate such upon the request of relatives of the deceased for insurance purposes. Anyway, in the final collaed statistics, only “Death under Inquiry”, and not “Suicide “ is an acceptable entry




Figure 1. Suicide reporting process, Homicide Division,
Manila City Police Department


Spot reports from January to June 2007 at the Homicide Division of the Manila City Police Department were reviewed to identify possible cases of suicide. Only 2 of 30 reports indicated probable suicide.

It is important to remember that only deaths are reported to the above Homicide Division. Suicide attempts are usually brought to the hospital and should be reported to the precinct in the catchment area of the hospital.

Suicide Media Reporting

Media play a significant role in providing a very wide range of information in varied ways. It has an equally significant influence community attitudes, beliefs and thus may play a role in suicide prevention. There is evidence that media report on suicide cases can influence other suicides. One of the earliest known associations between the media and suicide arose from Goethe’s novel The Sorrows of Young Werther, published in 1774. In that work the hero shoots himself after an ill-fated love, and shortly after its publication there were many reports of young men using the same method to commit suicide. Television newspaper and radio reports on suicide, particularly if it is a celebrated case, influence suicide behavior of the population. More recently, the internet has become a venue for discussing suicide among people who do not even know each other. There are now websites where those committing suicide are written about, some even revered, and affect other people’s perception of suicide. Suicide now poems hound the internet.

In a study on media representations of mental health and mental illness, over a two week period, there were three reports of suicide in tabloid front pages. There were similar reports in broadsheets but in the “Crime Columns” or “Police Beats”. Interview of reporters on information source on suicide revealed that all were from police blotters. With the posting of Spot Reports in the precinct, it is no wonder why details, even names, addresses and other personal details of the deceased, are out in the papers. In the same media monitoring period, a popular radio station aired and interview with a wife whose husband hang himself. With the wife crying over the radio, blaming herself for her husbands death, the issue was obviously mishandled.

Hospital Suicide Reporting

Two cases were studied to illustrate suicide reporting in the hospital, showing how the statistics get lost in the course of treatment.

Case 1 is an 18 y/o female, college student, who was being treated for depressive disorder. On her first week of treatment, after being scolded by her mother, she took 10 tablets of an antidepressant. She was noted to have laughing spells and poor sleep. She was brought to the emergency room of a government medical center. She was given gastric lavage while at the emergency room. Because there was no hospital bed available, she stayed at the emergency ward throughout the course of her 3-day stay. She was discharged improved as a case of Antidepressant overdose (venlafaxine). No referral to a psychiatrist was made during her hospital stay. She was however advised to seek psychiatric consult upon discharge. The hospital has a Section of Psychiatry under the Department of Internal Medicine and has regular out-patient psychiatric services.

Case 2 is a 17 y/o male college student who slashed his wrist for the first time. The cut was so deep that it required surgical intervention to prevent nerve injury. The adolescent, having had no previous history of psychiatric disorder, was admitted at the Surgery Ward of a teaching and training hospital that has its own Department of Psychiatry with accredited residency training program. After 7 days of hospitalization, the patient was discharged. No psychiatric referral was ever made. One year after attempting suicide, the patient sought consultation with a psychiatrist but refused pharmacologic intervention.

The above two cases clearly illustrate how the diagnosis of suicide gets lost in the process of hospitalization. In the first case, there is no existing referral procedure for admitted patients with self-inflicted conditions. The psychiatrists are engaged mostly at the out-patient clinics. In the second case, there is a Consultation Liaison Section with a referral procedure in place for in-patient suicide cases. The case was however missed in this instance. Further probing of the hospitalization circumstances revealed that the admitting surgeon was a relative of the patient and did not refer the patient. In this hospital, there is no referral system for cases treated at the emergency room who are not admitted to the wards.

In both instances, suicide statistics from hospitals become problematic, too. But beyond the statistics is the mental health service that was due these patients but were missed.

Review of the diagnoses recorded in the referral sheets, psychiatry ward and emergency ward census showed the inclusion of only the Axis 1 diagnosis. Although the charts may indicate suicide attempt of deliberate self-harm, the information is lost when data is collated.

Conclusion and Recommendation

The number of suicides is often underestimated, with the extent of underestimation varying from country to country. Reasons for underestimation, aside from f\gross i\under-reporting and lack of a reporting system include inability to ascertain suicide as the cause of death, stigma, social and political factors, and even insurance regulations.

The issue of reporting may treated in two ways: first is the reporting of a case of suicide by media, that is, depiction of suicide; and second, reporting of the incident to come up with a measure of magnitude. For purposes of this paper, the latter is discussed.

Suicide rates are difficult to establish. The nature of suicide in itself lends it to difficulty in reporting. Reasons have been mentioned above. While deaths are difficult both to track and to ascertain, the situation is more difficult with suicide attempts. Non-fatal suicide behavior are difficult to document partly because of stigma, and social and cultural issues.

Suicide rates are frequently compared across countries. In situations where comparison of suicide rates and ratios are done, one must remember that procedures for recording mortality data (for example, being entered as Death Under Inquiry), seriously affect comparability. Extra caution should also be observed in deriving rates for small populations such as the ones presented in this paper. For example, the 17 deaths at the National Center for Mental Health where there is an average daily in-patient of 3,700 can not be extrapolated to generate the suicide rate of 7/100,000 population which is correctly derived mathematically. Non-fatal suicide behavior are difficult to document partly because of stigma, and social and cultural issues. If reported rates refer to small populations (e.g. cities, provinces or even small countries) their interpretation requires extra caution, since just a few deaths may radically change the picture.[10]

Based on the above description and analysis of suicide rates and ratios, it is possible to initiate a reporting system in the police department and hospital setting. Reporting system in the police department may entail more work. It will have to involve reviewing spot reports, identifying likely cases of suicide, following through relatives or key informants of the deceased, doing psychological autopsy, and eventually ascertaining suicide behavior. At the hospital setting, institutionalization of a referral system with clear guideline, and urging the use of multi-axial diagnosis for psychiatric patients, may generate more reliable data.

While there appears to be no immediate plan to design a national suicide prevention program, there is a dire need to establish reliable suicide rates and ratios. Macdonald’s work is an example of how keen observation can generate hypotheses on suicide behavior. Knowledge and understanding of suicide behavior can contribute to public health, for example, suicide prevention. The Macdonald study now even challenges us to think if we do have a “low” suicide rate or how suicides seem to be reported more in urban settings in the Philippines.

In a recent happiness index survey, Filipinos were found generally happier than other people. Using “Measuring Progress of Societies: Would You Rather Be Rich Or Would You Rather Be Happy?” , from a scale of zero to 10, Filipinos’ happiness rating according to the World Database of Happiness was at 6.4, tying at the 40th to 43rd place with Czechoslovakia, Greece and Nigeria. Statisticians however think that “when one looks at the happiness data and the suicide rates among nations, it is quite clear that nations which score high in happiness do not necessarily have lower suicide rates,” [11]
MacDonald's study raises questions about the vulnerability of small communities like the Kulbi, as it does the vulnerability of the generally happy Filipino. If happiness is “cultural”, is suicide “uncultural”?
There is value in taking a second – and closer – look at our suicide rates and ratios.

[1] Associate Professor, Faculty of Management and Development Studies, University of the Philippines Open University, College, Los Baños, Laguna, Philippines. Email: dnadera@upou.net.
[2] World Health Organization, 2001
[3] Jularbal NAE (1994) Review of suicide cases among in-patients at the National Center for Mental Health: a 10 –year study. (unpublished)
[4] Enriquez, RY (1986) Suicide Patterns in the 80’s: The UST Experience.
[5] Morales, Imelda P. (1979) Suicide among Filipino Adolescents: A Study of Thirty Cases. The Philippine Journal of Psychiatry 1979 June; 9(1): 32-35

[6] Philippine global school based health survey (2003)
[7] Macdonald CJH (2003). Urug. An Anthropological Investigation on Suicide in Palawan, Philippines. Southeast Asian Studies, Vol. 40, No. 4, March 2003
[8] Macdonald CJH (2003). Urug. An Anthropological Investigation on Suicide in Palawan, Philippines. Southeast Asian Studies, Vol. 40, No. 4, March 2003
[9] World Health Organization (2000) Preventing Suicide: A Resource For Media Professionals
WHO/MNH/MBD/00.2

[10] [10] World Health Organization (2000) Preventing Suicide: A Resource For Media Professionals
WHO/MNH/MBD/00.2

[11] Filipinos happier than folk in most rich countries (Business Mirror, August 14, 2007)


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Reposted here with permission from the author. Dahil napapanahon, period.