Dr Murad Moosa Khan, Chairman of the Department of Psychiatry at AKU, discusses the prevalence of suicide in Pakistan, and the best way to deal with this phenomenon.
What are the leading causes of suicide in Pakistan?
The most glaring thing that has come up over the past few years is that the number of suicides has gone up. This could be because no one has been tracking data properly in the past but, at least since the mid-90s, when we have been gathering information, we have seen cases of suicide increasing. The causes have not changed as much. People commit suicide because of a disturbed mental state. The contributing factors or the triggers (which lead to the actual suicide) can vary — I think in Pakistan economic and social factors play a big role.
In the media, it is often said that people commit suicide because of poverty, or unemployment, but research in Pakistan and everywhere else shows that it is actually mental illness that causes suicide... the person may be clinically depressed. And if you ask, ‘Isn’t poverty enough to make you clinically depressed?’ I would say, about 50% of Pakistan lives around the poverty line. Yet a very small percentage of these people will actually commit suicide. People commit suicide because of biological, genetic and personal factors.
What are the numbers for suicides in Pakistan like?
We estimate that in Pakistan today, about 5,000-7,000 suicides take place yearly. We have 2,000-3,000 documented cases, and you can safely double that number because most cases aren’t reported. But the important thing to note is that for every suicide, there are at least 10 to 20 suicide attempts. So if you are looking for a safe figure, then we could say about 5,000 suicides yearly along with anywhere between 50,000 and 100,000 suicide attempts.
In your experience, how do people in Pakistan deal with the idea of suicide, and seeking help for suicidal thoughts?
Here suicide is condemned very strongly on religious grounds and people feel they can’t verbalise something that is going against religious beliefs. Also, there is a huge stigma surrounding seeking help for emotional problems. We have very few crisis centres for these things and a dearth of hotlines. Many people could be saved if these facilities were available.
What are the stages that a person goes through before they contemplate suicide?
There is a path that people follow leading up to the suicide attempt. People first become mentally disturbed, then they cross a certain threshold and become hopeless. When they become hopeless they enter into depression, or clinical depression, and then they may not see any way out of their predicament other than suicide.
What then are the warning signs?
If you want to identify a person who may be suicidal — you want to be looking at the symptoms that they exhibit before they become suicidal. People who start having suicidal thoughts may become withdrawn, they may stop taking care of themselves, they may suffer at work, their grades will slip, or a person will not be as outgoing as they used to be. The person may stop eating and drinking normally, they may stop going out as much as they used to, their hygiene may suffer, and they may seem preoccupied. Then beyond that, a person may start dropping clues in conversation, saying things like, “I don’t feel like living” or “I wish I was dead.” There are stages, and anyone of us who is sensitive enough to see this change in friends or family members should get the person to seek professional help.
What should concerned people do if a person displaying these tendencies refuses to get help? ?
We are often approached by family members who tell us that the person in question refuses to get counselling. We tell friends or family members to continue talking to the person and to be there for them. Ultimately, in 90-95 per cent of cases the person does eventually accept the idea of getting professional help. Supporting a suicidal person is extremely important, to counter the feeling that the person has that “people don’t understand me and I’m all alone.”
So say that someone reading this is having suicidal thoughts, what should they do?
The moment you share your problems, it shrinks by 50%. Talk to a friend, a confidante, a family member. And the responsibility of the person he or she shares it with is to simply lend an ear. Beyond that, it is important to seek professional help if these feelings are not going away. That professional help may be to simply talk it over and assure the person that these are normal thoughts and that ‘this too shall pass’. Or the person may need more intense counselling and if the person is entering into a state of clinical depression, then treatment will be needed, which is not necessarily medical treatment.
Do men and women react differently to the kind of emotional turmoil that leads to suicidal thoughts?
Yes, women are much more willing to talk about their emotional problems, which is why rates of suicide in women are less than the rates of suicide in men. Though more women attempt suicide than men, more men actually die as a result of suicide. Generally, women’s ability to withstand pain, physical and emotional, is much higher than men’s ability to withstand pain. Men definitely need to be more like woman in terms of sharing their emotions.
In how many cases are suicidal tendencies the result of a physical or biological problem — like a chemical imbalance — and how often is it external circumstance such as poverty or other issues?
In every case, you have to use something called the bio-psycho-socio model. So every case, whether it is of depression, arthritis or heart disease, you have to look at the biological, social and psychological components. So for example if I’m seeing a person who has a strong family history of depression and has a stable life otherwise, then I’ll look at biological factors more closely and so on. Some people, depending on this, may require some counselling but no medication, others may have different needs. The main thing to remember is that the majority of people who commit suicide have a diagnosable mental illness at the time that they take that step. And this is depression. Almost 90 per cent of people who commit suicide are suffering from clinical depression. So if you just address this disease — you will prevent a lot of people from committing suicide.
So if a person has a family history of depression should they be on guard against such tendencies?
Yes, if you have a family history of depression, or a parent who has committed suicide, you have to make sure you don’t do things that are risk factors for depression or suicide.
Such as alcoholism, for example, or leading an unhealthy lifestyle, entering into toxic relationships that are damaging or abusive. A person with such a history must also avoid taking on a level of stress that would result in a breakdown. You should live within certain physical and emotional boundaries. When you go beyond them, you are in danger zone. Just like if you have a family history of heart disease then you should certainly avoid fatty foods and obesity.
We tend to view mind and body as separate — you’re saying that’s not the case?
Absolutely, mind and body work together. An unhealthy body will lead to an unhealthy mind - we have to achieve a balance.
How important is spirituality in this context?
Very important. It is as important as staying physically healthy and avoiding risky behaviour. Now to some, spirituality may mean praying namaz five times a days or going on multiple Hajjs. For others it may mean meditation. Whatever your belief system is, you must practice it beyond the ritualistic aspect. Having a larger purpose in life lets you stay connected to life, whether it’s a cause or a hobby.
Are there facilities in Pakistan where people with suicidal thoughts can seek help?
There are several institutions, mostly in urban areas. The problem is accessibility and affordability for the general public. 90% of healthcare costs are out of your pocket, so what can you do? The majority of suicides are preventable, so these are all preventable, needless deaths that are happening.
Legally, where does suicide stand in Pakistan?
Suicide needs to be decriminalised. This law was set up because it is based on religious edicts, but now if you look at the figures it is clear that the deterrence value has been lost. According to data from across the world, suicide rates in Islamic countries were traditionally less than suicide rates in other countries. But now, suicide rates in countries like Pakistan, Bangladesh, Iran and Turkey are going up. The ‘deterrence factor’ of Islam is losing its effect in these countries. Poverty, deprivation, lack of justice are all very important factors. Just look at Iran, which is a conservative, theocratic society. The suicide rates are going up, and in the rural areas women are burning themselves, one of the most common methods in that area. In Pakistan and Bangladesh the most common form of suicide is by consuming pesticides.
When someone commits suicide — what does this do to the rest of the family?
Psychologically and emotionally, people can be destroyed and it takes years to recover. The family will feel all sorts of emotions, from anger to guilt and depression. And then there is a chance of the cycle repeating itself.
Published in The Express Tribune, Sunday Magazine May 22nd, 2011.