Understanding Suicide and Self-Harm in Adolescents

Suicide has become more prevalent in the Singaporean community, where cases have increased in all age groups over the last few years[1]. The presence of the COVID-19 pandemic has significantly impacted the physical and psychological health of individuals across various age groups, including adolescents. In fact, it has burdened adolescents significantly as they experience the academic stress of online learning, unconducive learning environment, loss of routine and social deprivation. As a result, there has been an increase in symptoms of psychological distress such as self-reported stress, anxiety and depression amongst adolescents[2]. Accumulation of psychological distress, and limited resources and knowledge in dealing with the stressors have led some adolescents to commit suicide and/or self-harm.

Suicide can be defined as a self-directed injurious or self-destructive behaviour that is performed with the intention to end one’s life and result in death[3]. It is a complex and multifaceted issue. Individuals who resort to suicide often do so due to the overwhelming feeling of distress, pain, and hopelessness[4]. In comparison, self-harm is a non-suicidal act whereby individuals intentionally injure themselves either through cutting, scratching, abusing medication, hitting themselves, or even ingesting toxic substances for various reasons[5]. It is a form of a maladaptive coping mechanism used as a distraction to express feelings that cannot be put into words and release emotional pain.

Individuals who engage in self-harm are likely to develop suicidal behaviours if no intervention is made[6]. Despite the difference in the nature of suicide and self-harm, it is crucial to recognise the harm to one’s life. Individuals who engage in self-harm do not intend to end their lives. However, repeated acts and an increase in the threshold of pain will risk the individual committing suicide. Hence, it is vital to address both issues to prevent more loss of lives and reach out to more adolescents to help them cope with their daily stressors.

STATISTICS OF SUICIDE AND SELF-HARM
Numerous lives are lost every year due to suicide. It was reported that suicide is the world’s third leading cause of death in adolescents aged 15 to 19[7]. The World Health Organization (WHO) reported that every year, 100,000 people die due to suicide. Suicide is also very much prevalent in Singapore. The Samaritans of Singapore (SOS) reported that suicide is the leading cause of death for those aged 10 to 29; it is accountable for the loss of 452 lives in 2020. Statistics showed an increase of 13 percent[8] from 2019 and deaths caused by suicide continue to soar as it accounts for one-third of all reported deaths for those aged 20 to 29[9]. The Immigration and Checkpoints Authority (ICA), where deaths are reported and registered, further reported that there had been an increase of 37.5 percent of suicide cases from 2019 to 2020 for those aged 10 to 19[10].

Contrary to suicide statistics, it is harder to collect accurate statistics on the occurrence of self-harm. It is even more challenging to collect statistics for adolescents as self-harm is often a secretive act. It is anticipated that they would hide their scars and worries behind a cheerful face. A study among Singaporean adolescents in an outpatient setting reported that the prevalence of self-harm has been consistent at 23.1 percent from 2013 to 2018[11]. The study also noted that consistency in prevalence implies that self-harm continues to be a significant feature in adolescents presenting psychiatric symptoms.

School closures and the abrupt adoption of hybrid learning during the pandemic have also impacted adolescents. Disruption to school routine has caused an increase of distress, decline of mental health and breach of child protection[12]. These are reflected in the increasing cases of suicide. Moreover, online learning has resulted in an increase in lack of interaction and social isolation[13]. Other than gaining knowledge, school serves a place for children to learn communication and social skills. Online learning limits adolescents’ physical and social interaction, which in return, can lead to feelings of loneliness and lack of motivation. Besides, as they are in an ‘isolating environment’, there could be a lacking presence of someone who is able to monitor them, or for them to lean on or voice out their concerns. Earlier this year, there was a case involving a 16-year-old boy who hanged himself using shoelaces[14]. He had coiled and tied the shoelaces around each other to make them sturdier. Who would’ve known that a child would make use of a harmless everyday item to take his own life? So how badly are adolescents affected by the abrupt changes brought about by the pandemic and how susceptible are they to suicide?

FACTORS OF SUICIDE IN SINGAPORE ADOLESCENTS
Adolescents are especially at risk as they are still in the developmental stage. They are still undergoing physiological and psychological changes and have yet to develop the appropriate skills to cope with many new challenges in life. Hence, the lack of skills and pressures from the outside world dramatically impacts the mental status of the young mind[15]. Senior Assistant Director of SOS, Ms Wong Lai Chun, said that adolescents have yet to develop adequate coping mechanisms, hence the combination of different stressors may lead them to feel overwhelmed and unable to cope.

A study conducted by the Ministry of Social and Family Development (MSF) on Singaporean adolescents who attempted suicide reported experiencing stressors in the domain of social, family, academic and financial matters[16]. Both suicide and self-harm are associated with various risk factors.

Firstly, the most prominent risk factor would be academic stress, where exams have been the primary cause of students’ suicide[17]. This is not surprising, given the heavy emphasis on academic achievement here[18]. This leaves little time for healthy activities, exercise, and human interaction, which promotes better mental health and less suicidal ideation[19]. This is due to more time spent on the desk and the desire to perform well. The pandemic has further amplified these feelings in adolescents. They witnessed adults losing their job, closure of multiple businesses, and so on. The abrupt changes, loss of routine, lesser human interaction and activities have further contributed to adolescents’ inability to cope with pressures and high expectations, driving them towards despair, anxiety, and suicide[20].

Secondly, the absence and/or lack of social support. This includes an invalidating home environment[21], low perceived support, parent-child conflicts, family aggregation of suicidal behaviour[22], childhood trauma, and stigmatisation against mental health issues[23]. Frequent conflicts within the family and lack of support contribute to psychological distress. As a result, adolescents are likely to experience failed belongingness and eventually feel that there is nothing to live for[24]. Parents who lack awareness of mental health issues might also seek traditional medicine practitioners or spiritual healers to counter the problems faced by their children[25]. As a result, it further deters adolescents from opening up and seeking appropriate help. Along with the risk factors of suicide, the mental conditions of anxiety and depression that some adolescents have further intensify the suicidal thoughts in them[26].

In comparison, protective factors of suicide and self-harm include strong family ties, extended kin and social support networks[27], perceived caring, support and quality of communication[28]. Protective factors can mitigate or even eliminate the risk of suicide, increasing the health and well-being of adolescents. A strong support system is vital in adolescents as it promotes social cohesion and enhances resilience to stress. Moreover, it also creates a safe space for adolescents to share their concerns and worries, which helps to regulate their emotions and release stress. It has also been reported that adolescents with an effective social support system within the family and community helped buffer against many life stressors[29]. These factors play a part in altering the suicidal threshold, hence, building a safe environment for  adolescents will help them to be less susceptible to suicide and self-harm.

NO GROUP IS EXEMPTED
While the article focuses on adolescent’s suicide, it is also essential to note that no one is exempted. The recent pandemic has seen a rise in suicide in all age groups, particularly the elderly population. The number of suicide cases within the elderly population increased by 26 percent from 2019.

The Chief Executive of SOS, Gasper Tan, said that the elderly are more likely to suffer from social isolation and financial worries as they have difficulty adapting to the constant changes[30]. The pandemic has caused them to abruptly halt various activities and stay at home for an extended period. It has also caused various activities and initiatives for seniors to be conducted online.

Despite the continuous initiatives, those who are not digitally savvy might feel lost or helpless. As a result, they experience prolonged feelings of loneliness, inactivity due to isolation, psychological distress and impaired social and family relationships[31]. Hence, shifting activities online might not be a suitable option for the elderly population.

With this, it is crucial to understand that everyone is equally affected by the pandemic but with differentiating levels of impact. Hence, this issue needs to be addressed to prevent the loss of more lives.

TACKLING SUICIDE AND SELF-HARM
Singapore has seen various progress in raising awareness and helping those affected. In addressing the stigma around mental health illness, voluntary welfare organisations and initiatives such as the Silver Ribbon Project and the Singapore Association of Mental Health (SAMH) have actively conducted awareness and public education programmes, encouraging early treatment to address the underlying stigmatisation[32].

Secondly, the Response, Early Intervention and Assessment in Community Mental Health (REACH) service was developed in 2007 to support students with mental health issues. The main objectives of REACH are: firstly, to improve youth’s mental health via early assessment and intervention; secondly, to build the capacity of school and community partners to detect and manage mental health through training and support; and thirdly, to build a mental health support network for youths in the community. REACH organisations are strategically located by region to serve the regional school zones in Singapore[33].

Thirdly, the Samaritans of Singapore and Temasek Foundation have organised the #chatsafe programme and guidelines and launched a social media campaign called #PauseBeforeYouPost to help youths navigate suicide. The #chatsafe guidelines aim to help youths engage in safe and effective conversations with their family and peers, equip youths with relevant skills and knowledge to counter suicide-related content and manage their mental health. At the same time, SOS launched the campaign to reframe mindsets and empower people to reach out to those in distress. This initiative was launched to mitigate the increasing suicide-related content online. Although it is crucial to raise awareness and help those who are in distress, some content might be distressing or harmful to others[34].

In regard to the COVID-19 pandemic, schools and institutes of higher learning in Singapore have addressed issues of mental health, well-being and personal resilience in the school curriculum. One of the significant initiatives was the employment of trained teachers and staff members to aid in identifying signs of distress in students, monitor their wellbeing, and provide guidance and support[35].

More and more initiatives can be seen from various organisations in Singapore to help individuals cope with their distress. Besides the various interventions developed, various organisations have also established a hotline for those who are contemplating suicide or have no one to talk to. However, despite the developments and efforts that various organisations have conducted, suicide and self-harm still prevail. Hence, all of us need to take the first step in keeping our close ones in check as humans rely and depend on each other for support. Those at risk will be more comfortable to open up with the existence of a support system and community. ⬛

If you feel distressed or know someone who is feeling distressed, please approach these organisations for assistance.

  • Samaritans of Singapore:
    1800 221 4444 (24 hours), or
    1767 (24 hours)
  • Singapore Association of Mental Health:
    1800 283 7019
    (Monday to Friday, 9am-6pm)
  • Emergency Helpline (Institute of Mental Health):
    6389 2222 (24 hours)
  • Tinkle Friend:
    1800 274 4788
    (Monday to Friday, 9.30am-5pm)


1 Gene, N. K. 452 Suicides Reported in Singapore in 2020 Amid Covid-19, Highest Since 2012. The Straits Times. 2021, July 8. Retrieved from: https://www.straitstimes.com/singapore/452-suicides-reported-in-singapore-in-2020-amid-covid-19-highest-since-2012
2 Thakur, A. Mental Health in High School Students at the Time of COVID-19: A Student’s Perspective. Journal of the American Academy of Child & Adolescent Psychiatry, 59(12), 2020. pp. 1309–1310. Available at: https://doi.org/10.1016/j.jaac.2020.08.005
3 Goo, K. L. S., et. al. Identifying the Patterns of Self-Harm and Suicide Attempts in Children and Adolescents in Singapore. ASEAN Journal of Psychiatry, 18(2), 2017. Available at: https://www.aseanjournalofpsychiatry.org/articles/identifying-the-patterns-of-selfharm-and-suicide-attempts-in-children-and-adolescents-in-singapore.pdf
4 Wong, J. C. M. Predicting Suicide and its Prevention. Annals Academy of Medicine, 47(9), 2018. pp. 357–359. Available at: https://www.annals.edu.sg/pdf/47VolNo9Sep2018/V47N9p357.pdf
5 Smith, M., et. al. How to Feel Better Without Hurting Yourself. Limitless. 2018. Accessed August 20, 2021, from at: https://www.limitless.sg/self-harm
6 Samari, E., et. al. An exploration of differences between Deliberate self-harm with and without suicidal intent amongst a clinical sample of young people in Singapore: a cross-sectional study. International Journal of Environmental Research and Public Health, 17(4), 2020. pp. 1429–1441. Available at: https://doi.org/10.3390/ijerph17041429
7 Wardhan, R., and Mudgal, P. Understanding the predisposing risk factors of young suicide. International Journal of Research in Medical Sciences, 8(12), 2020. pp. 4530–4542. Available at: https://doi.org/10.18203/2320-6012.ijrms20204985
8 Samaritans of Singapore. Singapore reported 452 suicide deaths in 2020, number of elderly suicide deaths highest recorded since 1991. 2021, July. Retrieved from: https://www.sos.org.sg/pressroom/singapore-reported-452-suicide-deaths-in-2020-number-of-elderly-suicide-deaths-highest-recorded-since-1991
9 Awang, N. Number of suicides continues to be highest among those in their 20s: SOS. 2020, August 4. Retrieved from: https://www.todayonline.com/singapore/number-suicides-continues-be-highest-among-those-their-20s-sos
10 TODAY. Covid-19: Suicide rate among 10-19 age group rises in 2020 year-on-year. 2021, July 28. Retrieved from: https://www.todayonline.com/singapore/covid-19-suicide-rate-among-10-19-age-group-jumps-375-2020-year-year
11 Lauw, M. S., et. al. Deliberate self-harm among adolescent psychiatric outpatients in Singapore: prevalence, nature and risk factors. Child and Adolescent Psychiatry and Mental Health, 12(1), 2018. pp. 35–41. Available at: https://doi.org/10.1186/s13034-018-0242-3
12 Renjan, V., and Fung, D. S. S. Debate: COVID-19 to the under 19 – a Singapore school mental health response. Child and Adolescent Mental Health, 25(4), 2020. pp. 260–262. Available at: https://doi.org/10.1111/camh.12426
13 Kentucky Counseling Center. Mental health effects of online learning. 2021, April 20. Retrieved from: https://kentuckycounselingcenter.com/mental-health-effects-of-online-learning/
14 harmonytee. The Boy Who Shoelaced Himself (To Death). Harmony Funeral Care. 2021, January 22. Retrieved from: https://www.singaporefuneralservices.sg/2021/01/22/the-boy-who-shoelaced-himself-to-death/
15 Min, A. H. MOE, MSF ‘very concerned’ about spike in youth suicides; experts say more support and awareness necessary. CNA. 2021, February 9. Retrieved from: https://www.channelnewsasia.com/singapore/moe-msf-very-concerned-about-spike-youth-suicides-experts-say-more-support-and-awareness-necessary-862516
16 Wong, J. C. M. Predicting suicide and its prevention. Annals Academy of Medicine, 47(9), 2018. pp. 357–359. Available at: https://www.annals.edu.sg/pdf/47VolNo9Sep2018/V47N9p357.pdf
17 Wasserman, D., et. al. Suicide prevention in childhood and adolescence: a narrative review of current knowledge on risk and protective factors and effectiveness of interventions. Asia-Pacific Psychiatry, 13(3), e12452, 2021. Available at: https://doi.org/10.1111/appy.12452
18 Loh, C., et. al. Suicide in young singaporeans aged 10–24 years between 2000 to 2004. Archives of Suicide Research, 16(2), 2012. pp. 174–182. Available at: https://doi.org/10.1080/13811118.2012.667335
19 Wasserman, D., et. al. Suicide prevention in childhood and adolescence: a narrative review of current knowledge on risk and protective factors and effectiveness of interventions. Asia-Pacific Psychiatry, 13(3), e12452, 2021. Available at: https://doi.org/10.1111/appy.12452
20 Wardhan, R., and Mudgal, P. Understanding the predisposing risk factors of young suicide. International Journal of Research in Medical Sciences, 8(12), 2020. pp. 4530–4542. Available at: https://doi.org/10.18203/2320-6012.ijrms20204985
21 Lauw, M. S., et. al. Deliberate self-harm among adolescent psychiatric outpatients in Singapore: prevalence, nature and risk factors. Child and Adolescent Psychiatry and Mental Health, 12(1), 2018. pp. 35–41. Available at: https://doi.org/10.1186/s13034-018-0242-3
22 Wasserman, D., et. al. Suicide prevention in childhood and adolescence: a narrative review of current knowledge on risk and protective factors and effectiveness of interventions. Asia-Pacific Psychiatry, 13(3), e12452, 2021. Available at: https://doi.org/10.1111/appy.12452
23 Lauw, M. S., et. al. Deliberate self-harm among adolescent psychiatric outpatients in Singapore: prevalence, nature and risk factors. Child and Adolescent Psychiatry and Mental Health, 12(1), 2018. pp. 35–41. Retrieved from: https://doi.org/10.1186/s13034-018-0242-3
24 Samari, E., et. al. An exploration of differences between Deliberate self-harm with and without suicidal intent amongst a clinical sample of young people in Singapore: a cross-sectional study. International Journal of Environmental Research and Public Health, 17(4), 2020. pp. 1429–1441. Available at: https://doi.org/10.3390/ijerph17041429
25 Ibid
26 Min, A. H. MOE, MSF ‘very concerned’ about spike in youth suicides; experts say more support and awareness necessary. CNA. 2021, February 9. Retrieved from: https://www.channelnewsasia.com/singapore/moe-msf-very-concerned-about-spike-youth-suicides-experts-say-more-support-and-awareness-necessary-862516
27 Choo, C. C., et. al. Does ethnicity matter in risk and protective factors for suicide attempts and suicide lethality? PLOS ONE, 12(4), e0175752, 2017. Available at: https://doi.org/10.1371/journal.pone.0175752
28 Wasserman, D., et. al. Suicide prevention in childhood and adolescence: a narrative review of current knowledge on risk and protective factors and effectiveness of interventions. Asia-Pacific Psychiatry, 13(3), e12452, 2021. Available at: https://doi.org/10.1111/appy.12452
29 Choo, C. C., et. al. Does ethnicity matter in risk and protective factors for suicide attempts and suicide lethality? PLOS ONE, 12(4), e0175752, 2017. Available at: https://doi.org/10.1371/journal.pone.0175752
30 Gene, N. K. 452 suicides reported in Singapore in 2020 amid Covid-19, highest since 2012. The Straits Times. 2021, July 8. Retrieved from: https://www.straitstimes.com/singapore/452-suicides-reported-in-singapore-in-2020-amid-covid-19-highest-since-2012
31 Choo, D. Suicides in Singapore reach 8-year high in pandemic-hit 2020, with elderly suicides highest since 1991. TODAY. 2021, July 8. Retrieved from: https://www.todayonline.com/singapore/suicides-singapore-reach-8-year-high-pandemic-hit-2020-elderly-suicides-highest-1991
32 Lim, C., et. al. Child community mental health services in Asia Pacific and Singapore’s reach model. Brain Sciences, 7(12), 2017. pp. 126–136. Available at: https://doi.org/10.3390/brainsci7100126
33 Renjan, V., and Fung, D. S. S. Debate: COVID-19 to the under 19 – a Singapore school mental health response. Child and Adolescent Mental Health, 25(4), 2020. pp. 260–262. Available at: https://doi.org/10.1111/camh.12426
34 Samaritans of Singapore. Media Release – SOS and Temasek Foundation help youths navigate suicide with #chatsafe guidelines. 2021, May. Retrieved from: https://www.sos.org.sg/pressroom/sos-and-temasek-foundation-help-youths-navigate-suicide-with-chatsafe-guidelines
35 TODAY. Covid-19: Suicide rate among 10-19 age group rises in 2020 year-on-year. 2021, July 28. Retrieved from: https://www.todayonline.com/singapore/covid-19-suicide-rate-among-10-19-age-group-jumps-375-2020-year-year

 


Zuriati Zulfa Roslee is currently interning at the Centre for Research on Islamic and Malay Affairs (RIMA). She is also a final year student majoring in Psychology at International Islamic University Malaysia (IIUM).

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