Are You OK?

Mental Health in Singapore: Dr Jared Ng

Stress, Depression & Suicidality

 Objectives

• Depressive Illnesses
• Self-Harm & Suicide
• Awareness
• Prevention
Singapore Mental Health Study

Schizophrenia ~1-2%
Bipolar disorder ~1-2%
Singapore Mental Health Study Dec 2009
– Dec 2010
• 6616 Adult Singapore Residents (including Singapore
Citizens and Permanent Residents) aged 18 years and
above

• Lifetime prevalence
• Mental illness: 12.0%
• Depression: 5.8%
• Generalised anxiety disorder: 0.9%
• Obsessive compulsive disorder (OCD): 3.0%
• Alcohol dependence: 0.5%
Singapore Mental Health Study (SMHS) 2010
Singapore Mental Health Study (SMHS) 2010
Common Symptoms
Depressive Anxiety
Disorders Disorders
Fear
Panic
Excessive worries
Low mood Panic attacks Hypervigilance
Anhedonia Pain complaints
Weight loss/gain Compulsive
Poor sleep acts
Poor concentration
Agoraphobia
Problems sleeping

Fatigue, giddiness, GI complaints,

headache, chest discomfort,
insomnia, poor appetite
Myths of Depression

• Its normal for people to be moody

• Depressed people are mentally weak and need to pull
themselves together
• Talking about depression only makes it worse
• People who talk about suicide don’t commit suicide
• Telling on a friend is betraying a trust. If someone
needs help, they will ask for it
Loss

Depression: reaction to a loss

Failure
Separations

Death
Self

Illness
Depressive disorders

• Major depressive disorders (MDD)

• Dysthymic disorder
• Depression NOS
• Substance induced
• Secondary to General Medical Condition
• Disruptive Mood Dysregulation Disorder (DMDD)
 Diagnostic Criteria (MDD)
Five or more of the following symptoms are present most of the day,
nearly every day, during a period of at least 2 consecutive weeks

At least 1 1. Depressed mood

of these
2 symptoms
2. Loss of interest or pleasure in all, or almost all, usual activities

3. Significant weight loss or weight gain

4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate or indecisiveness
9. Recurrent thoughts of death or suicide
Symptoms must cause clinically significant distress or
impairment in social, occupational, or other important areas of
DSM-IV-TR™ 2000. functioning
Epidemiology

• Can occur at all ages from adolescent onwards

• Women twice as likely to become depressed
• Associated with:
• Lower socioeconomic group
• Divorced; separated; widowed and single status
• Family history of depression
Assessment and Treatment

• Suicidal?
• Inpatient?
• Social
• Psychological
• Biological
 Common Treatment Options
Antidepressant medications Selective serotonin reuptake inhibitors (SSRIs)
Other antidepressants (selective norepinephrine
reuptake inhibitors [SNRIs], atypicals)
Tricyclic antidepressants (TCAs)
Monoamine oxidase inhibitors (MAOIs)

Psychotherapies Cognitive therapy

Behavioral therapy
Interpersonal therapy
Psychoanalytically oriented therapy
Family therapy

Combined medication/psychotherapy
Other Electroconvulsive therapy
Phototherapy (light therapy)
Hospitalization
 • Interest is decreased
• Sleep affected
• Appetite affected
• Depressed Mood
• Concentration
impaired
• Activity change
• Guilt increase
• Energy decrease
• Suicidal thoughts

Symptoms
Cognitive therapy: To correct cognitive errors

• Filtering
• “Black and White” Thinking
• Overgeneralization
• Jumping to Conclusions
• Catastrophizing
• Personalization
• Control Fallacies
• Fallacy of Fairness
Depression and Suicide

• 15% of depressed patients commit suicide

• 10 times as many make suicidal acts
• Increased risk in:
• alcohol and drug abuse
• panic disorder, intense anxiety
• medical illness
• positive family history
• poor social support
• recent losses, unemployment
What is Suicide?

Dear parents
… The reason why I chose to end my life is that I have been
living in pain … Maybe this is because I have some mental
problem, and this is perhaps the result of not seeing the
doctor. … I choose to take my own life. … It is not that I
do not have the courage to live on but that I am simply too
tired to carry on living. Death could be a relieve to me.

 Suicide is an intentional act of self

destruction
Causes of Suicide
High Suicide Risk

• Hopelessness
• Suicidal intention
• Recent suicide attempt with
• Planning, last act, attempt to avoid discovery, no regret about attempt
• Environmental resources for attempt
• Unstable mental state, e.g. depressed
• Demographic risks (see next)
Handling the Suicidal

• Developing rapport
• Time
• Trust (empathy, objective)
• Truth
• Helping the Person cope
• Symptom treatment with medications
• Support
• Skills for problem solving
Helping the Suicidal
• Getting support e.g. SOS helpline
• Talking to the person
• Things the person still wants to do
• Think of all the important people and how they would react?
• No harm contract
• Crisis plan: what can the person do the next time if he/she
feels suicidal
• If needed, get professional help
Crisis Plan

• Important numbers:
• Doctor, psychiatrist, crisis helplines.
• I will call the following people…
• If I can’t get through I will………
• If that doesn’t work I will ………
• If all above fails I will take time out for 15 minutes and then…….
After Suicide

• Grief work
• E.g. trained counselors/social workers at Family Service Centres
• Supporting the family/friends/school
• Increased risk of depression among closed ones
 Suicide
- Prevention-
- Management -

Jared Ng
Emergency & Crisis Services
IMH
Rate of suicide compared to other countries

TABLE 1. Suicide Rates of Youth (Per 100,000) According to

Gender
Youth
(15–24
Country Year Years) Male Female
China (Urban) 1999 3.5 3.0 4.1
China (Rural) 1999 10.4 8.0 12.9
Hong Kong 2006 8.4 11.6 5.2
Japan 2008 15.4 20.2 10.1
Philippines 1993 2.7 2.7 2.7
Sri Lanka 1991 54.7 59.0 42.0
Singapore* 2000–4 7.8 8.4 7.2
Australia 2004 9.8 14.4 4.9
United Kingdom 2007 4.6 7.4 1.8
USA 2005 10.0 16.1 3.5
Russia 2006 25.8 43.7 7.4
Egypt 2009 0.1 0.1 0.0
Note. All data from WHO Statistical Information 2011, except (*)
which is taken from Chia, 2010.
 • Heterogeneous group
• Endpoint for multiple roads
• All share dilemma of no “better alternative”
Suicide • Clinician must understand “WHY”
• Clinician must know “HOW”
• Suicide acts are often impulsive and crises often fleeting
• Method used largely depends on availability
• Fewer than 10% of survivors, even of near-lethal suicide attempts, go
on to die by suicide
• Implication: preventing a suicide today likely saves a life in the long run
 • The Houston Study: Nearly Lethal
Suicide Attempts
• N=153 (15-34 year olds)
• Time between deciding to complete
suicide and taking action:
• <5 minutes 24%
Many Suicidal • <20 minutes 48%
Crises Are • <1 hour 70%
Fleeting • <8 hours 86%

Simon et al. 2001. Suicide & Life-

Threatening Behavior (The Houston study,
data from author)
Many Suicidal Crises Are Fleeting

• Eighty-two patients referred to a psychiatric university

hospital after a suicide attempt were asked questions within
3 days after the act.
• “…Kevin Hines was eighteen when he took a municipal bus to the
bridge one day in September, 2000. After treating himself to a last
meal of Starbursts and Skittles, he paced back and forth and sobbed
on the bridge walkway for half an hour. No one asked him what was
wrong. A beautiful German tourist approached, handed him her
camera, and asked him to take her picture, which he did. “I was like,
‘Fuck this, nobody cares,’ ” he told me. “So I jumped.” But after he
crossed the chord, he recalls, “My first thought was What the hell did
I just do? I don’t want to die.”
Approaches to prevent self-harm and suicide

1 2 3
Populational Measures for Govt Policy
measures at-risk
populations
 • School-based psychological well-being and
skills training programmes
• Gatekeeper training (eg, school teachers,
peers)
• Screening to identify those who might be at
risk
• Restriction of access to means used for self-
Population harm and suicide
• Improved media reporting and portrayal of
Measures suicidal behaviour
• Encouragement of help-seeking behaviour
• Public awareness campaigns
• Help-lines
• Internet sources of help
• Reduction of stigma associated with mental
health problems and help seeking
 • Psychosocial interventions for
adolescents at risk of self-harm or
suicide (eg, depressed adolescents,
abused individuals, runaway children)
At-Risk • Screening of those at risk (eg, young
offenders)
Population • Psychosocial interventions for
adolescents who have self-harmed
• Pharmacotherapeutic interventions for
adolescents at risk of self-harm or
suicide
 • Harnessing new media to promote
positive mental health and protect
Others young people from its harmful effects
(eg, pro-suicide websites)
Policy

• Promotion and integration of government policies on suicide

and self-harm across other risk domains such as substance
abuse and social care
 Media and Suicide
• "Werther effect"
• Copycat suicide
Responsible Media Reporting
• Simple Principle:
• if an individual in crisis reads the article, is the person more likely to
commit suicide or to seek help?
• Sensitive reporting
• E.g. avoid details, not front page
• Focus on warning signs and causes
• Provide sources of help
• Avoid normalising suicides
Barriers to Suicide
(Yes, literally barriers)