Nigeria: Addressing Rising Cases of Suicide Among Teenagers

Temitope Saka, a 17-year-old girl, died after drinking insecticide, Sniper, in the Igando area of Lagos State.

It was reported that when Saka became pregnant, her grandma insisted she packed out of the house.

A national daily reported that the victim drank the poison and began foaming in the mouth at her boyfriend's house.

She was rushed to the Igando General Hospital where she died.

Earlier, a 19-year-old girl, Uche Obiora, allegedly took Sniper at her boyfriend's house, which is a street away from Saka's grandmother's house.

Also, Chukwuemeka Akachi, a 400-level student of the Department of English and Literary Studies, University of Nigeria, Nsukka, (UNN) committed suicide on Monday.

It was gathered that the deceased carried out the suicide in the solitude of an uncompleted building located at Sullivan Road, Nsukka where he allegedly slipped into coma after taking two bottles of an insecticide, Sniper.

His unconscious body was however discovered by passersby. He was declared dead at UNN Federal Medical Centre.

A close friend of Akachi who preferred anonymity said Akachi posted a suicide note on his Facebook wall shortly before he committed suicide.

Simply put, suicide is the intentional taking of one's own life. Until now there have been several reports of adults jumping into the Lagos Lagoon and others hanging themselves. But the trend has dramatically changed in the last few years. More teenagers are taking their lives especially through poisoning themselves.

Why?

According to the World Health Organisation (WHO), while the link between suicide and mental disorders (in particular, depression and alcohol use disorders) is well established in high-income countries, many suicides happen impulsively in moments of crisis with a breakdown in the ability to deal with life stresses, such as financial problems, relationship break-up or chronic pain and illness.

In addition, experiencing conflict, disaster, violence, abuse, or loss and a sense of isolation are strongly associated with suicidal behaviour. Suicide rates are also high amongst vulnerable groups who experience discrimination, such as refugees and migrants; indigenous peoples; lesbian, gay, bisexual, transgender, intersex (LGBTI) persons; and prisoners. By far the strongest risk factor for suicide is a previous suicide attempt.

It is estimated that around 20 per cent of global suicides are due to pesticide self-poisoning, most of which occur in rural agricultural areas in low- and middle-income countries. Other common methods of suicide are hanging and firearms.

A consultant psychiatrist, Lagos University Teaching Hospital (LUTH) Idi Araba and coordinator Suicide Research and Prevention Initiative (SURPIN), Dr. Raphael Ogbolu, told The Guardian that there are peculiarities of those within ages 13-35. The first thing to consider, Ogbolu said, is the period they live in, which he described as the Millennials and Generation Z.

He said the Millennials (Generation Y) are considered to be those born 1980 - 1994 and tend to be raised by single parents, and they are technologically wise.

According to the psychiatrist, Generation Z (post-Millennials, iGeneration, Gen Tech, Digital Native) are those born between 1995 and 2010/2014. They are less traditional and are more likely to be single parents, and are more entrepreneurial, more into phones than Television. He said what these two generations have in common is arguably the advent of social media and the Millennials are likely to reach adulthood around year 2000 at about the time GSM came into Nigeria, this meant that their popular mode of communication was less likely to be face-to-face, and as such both generations more often lived in a virtual world where social media gained a lot of prominence.

Ogbolu said they are therefore more likely to have less social and interpersonal skills compared to the older generations and the problem with this is that a lot of 'make believe' and fake personalities come into play.

Ogbolu added: "For that reason, we have children who will become sad because they cannot show off pictures of their family on vacation abroad when they see their mates showing off such pictures, even if they are fake. This in turn can affect self-worth and lead them to question. This is made worse by a technological world where someone can create a photo-shopped image of a 'beautiful' person. All this does is to diminish the self-esteem of a child who already lacks self-belief and confidence."

He said cyber bullying is also another accompaniment of social media, which these young people have to now deal with. "People who would not ordinarily be bold enough to abuse and bully others are now able to do so in the virtual world, and this has precipitated depression and suicidal thoughts among children who are less resilient... ," Ogbolu said.

The psychiatrist said the other peculiarity with these generations is the advent of designer drugs of abuse and they are more exposed to traditional drugs of abuse already, and with the internet making the world a small global village, they are also exposed to designer drugs that the previous generations could not have ever imagined.

Ogbolu said a third peculiarity that the youth have to deal with is the fact that it cannot censor information as effectively as it should and as such young people are exposed to a barrage of information that may not be age-appropriate and which may not be based on fact.

Global burden

Suicide accounts for about one million deaths worldwide annually, and for every death by suicide 20-25 more have attempted, according to the WHO. The Global Health Observatory puts the global age-standardised suicide rate at 11.4 per 100,000 people, and suicide is the second leading cause of death among those aged 15-29 years. The rate in Nigeria is put at 9.5/100,000. It has been strongly linked to depression, and also drug abuse, directly or in association with depression.

While suicide is not a new occurrence globally and locally, there is a worrying concern that youth suicide may be on the rise. This is particularly troubling for countries, like Nigeria, that have a relatively youthful population, where they make up a sizeable number and are the major productive age group. To lose them to suicide has grave consequences for economic growth. Studies have found that the rate rises from 0.6/100,000 among those 14 years and younger to 6.9/100,000 among those aged 15 to 19 years. The rate of suicide attempts among adolescents has been put at 12 per cent.

In Nigeria, the SURPIN has found that about one-fifth of suicide cases seen at its affiliated institution are those aged 13-19 years, and that over 50 per cent of the crisis calls received through its hotlines are from those aged 13- 29 years; 27.8 per cent were students. This should worry every parent, and indeed any Nigerian who values life, considering that the Nigerian National Youth policy (2009) defines youth as those aged 18 -35 years, while the African Youth Charter defines it as 15 - 35 years.

Nigeria is not the only country with rise in suicide rates. In India, thousands of young people die by suicide every year, according to the National Crime Record Bureau. In 2015, they made up 6.7 per cent of all suicides, totaling to almost 9,000 deaths. Some experts, parents and officials blame the pressure to succeed in school.

In the United States (U.S.), according to study, more young people, especially girls, are attempting suicides by poisoning.

According to the study published penultimate week, the rate of suicide attempts by poisoning among young people in the US has more than doubled in the past decade and more than tripled for girls and young women.

Researchers at Nationwide Children's Hospital in Columbus, Ohio, and the Central Ohio Poison Center recorded the number of phone calls made to US poison centers between 2000 and 2018 for self-poisoning of children and young adults ages 10 to 24 that were believed to be suicide attempts.

Over the 19-year study period, there were 1.6 million intentional poisoning cases, of which 1.16 million (71 per cent) occurred in girls and young women, according to the findings, published in the Journal of Pediatrics.

In another report, officials said 19 students have taken their own lives in the Indian state of Telangana since mid-April, after the release of intermediate examination results.

Experts have criticized India's education system as a poor one in which students are under heavy pressure not just to pass examinations but also to exceed expectations at all costs.

Thousands of Indian young people die by suicide every year, according to the National Crime Record Bureau. In 2015, they made up 6.7 per cent of all suicides, totaling to almost 9,000 deaths. Some experts, parents and officials blame the pressure to succeed in school.

A study published February in The BMJ showed the number of deaths from suicide increased by 6.7 percent globally between 1990 and 2016.

While this study, which was produced by the Institute for Health Metrics and Evaluation, determined an overall uptick in suicides, the years of life lost globally have actually decreased when everything is averaged out.

Also, when the researchers adjusted for the age of the individuals when they died from suicide, they realized that the years of life lost rate from suicide has decreased by a third between 1990 and 2016.

These conclusions all came from analysis of data collected from the 2016 Global Burden of Disease Study, which reflects patterns of suicide mortality by age, sex, and socio-demographics across 195 countries. Overall, rates of suicides committed by men were higher than that of women across the world, save for when it came to the 15 to 19-year old age group. Suicide deaths are higher among men than women, but the ratio is much lower in the countries that stretch from southern India to China.

According to the WHO, every year close to 800 000 people take their own life and there are many more people who attempt suicide. Every suicide is a tragedy that affects families, communities and entire countries and has long-lasting effects on the people left behind. Suicide occurs throughout the lifespan and was the second leading cause of death among 15-29-year-olds globally in 2016.

Suicide does not just occur in high-income countries, but is a global phenomenon in all regions of the world. In fact, over 79 per cent of global suicides occurred in low- and middle-income countries in 2016.

Suicide is a serious public health problem; however, suicides are preventable with timely, evidence-based and often low-cost interventions. For national responses to be effective, a comprehensive multi-sectoral suicide prevention strategy is needed.

Challenges and obstacles

According to the WHO, stigma, particularly surrounding mental disorders and suicide, means many people thinking of taking their own life or who have attempted suicide are not seeking help and are therefore not getting the help they need. The prevention of suicide has not been adequately addressed due to a lack of awareness of suicide as a major public health problem and the taboo in many societies to openly discuss it. To date, only a few countries have included suicide prevention among their health priorities and only 38 countries report having a national suicide prevention strategy.

Raising community awareness and breaking down the taboo is important for countries to make progress in preventing suicide.

Globally, the availability and quality of data on suicide and suicide attempts is poor. Only 60 Member States have good-quality vital registration data that can be used directly to estimate suicide rates. This problem of poor-quality mortality data is not unique to suicide, but given the sensitivity of suicide - and the illegality of suicidal behaviour in some countries - it is likely that under-reporting and misclassification are greater problems for suicide than for most other causes of death.

The founder, of a Non Governmental Organisation (NGO), the Mind And Soul Helpers Initiative (MASHI) and Head, English Department, University of Lagos, Prof. Hope Eghagha lamented on the stigmatisation around mental health citing that once you let it known you visited a psychiatrist for help people will think you are mad, if it is in the office they look at you in a strange way.

"When people have a psychological break down there are all kinds of reason attributed to it. The most popular one in our country is the spiritual attack. Sometimes, they say you have offended the ancestors or the village people, that you have committed an act of taboo. You find some highly placed educated people still piloting such ignorance. We realised that one thing we need to do is to educate people that mental health is very important and mental health crisis can affect anybody without committing any offence and it does not need to be a spiritual attack. We come from a very superstitious society. We are looking at it from the scientific point of view that somebody who contemplates suicide, somebody with suicidal thoughts can be helped," he said.

The department head continued: "We need funding, we need partners, we do not say bring money but if you bring it is okay. For instance, partners you sell telephones, give us then we give to the trained personnel. You can also train helpers for us. Where a case is serious and the person needs a doctor, we need to subsidise the treatment. We need funds to do the documentary we talked about... ."

Solution

The WHO insists that suicides are preventable. The apex UN health agency said there are a number of measures that can be taken at population, sub-population and individual levels to prevent suicide and suicide attempts.

These include: reducing access to the means of suicide (example pesticides, firearms, certain medications); reporting by media in a responsible way; introducing alcohol policies to reduce the harmful use of alcohol; early identification, treatment and care of people with mental and substance use disorders, chronic pain and acute emotional distress; training of non-specialized health workers in the assessment and management of suicidal behaviour; and follow-up care for people who attempted suicide and provision of community support.

Suicide is a complex issue and therefore suicide prevention efforts require coordination and collaboration among multiple sectors of society, including the health sector and other sectors such as education, labour, agriculture, business, justice, law, defense, politics, and the media. These efforts must be comprehensive and integrated as no single approach alone can make an impact on an issue as complex as suicide.

Improved surveillance and monitoring of suicide and suicide attempts is required for effective suicide prevention strategies. Cross-national differences in the patterns of suicide, and changes in the rates, characteristics and methods of suicide highlight the need for each country to improve the comprehensiveness, quality and timeliness of their suicide-related data. This includes vital registration of suicide, hospital-based registries of suicide attempts and nationally representative surveys collecting information about self-reported suicide attempts.

WHO recognizes suicide as a public health priority. The first WHO World Suicide Report "Preventing suicide: a global imperative" published in 2014, aims to increase the awareness of the public health significance of suicide and suicide attempts and to make suicide prevention a high priority on the global public health agenda. It also aims to encourage and support countries to develop or strengthen comprehensive suicide prevention strategies in a multi-sectoral public health approach.

Suicide is one of the priority conditions in the WHO Mental Health Gap Action Programme (mhGAP) launched in 2008, which provides evidence-based technical guidance to scale up service provision and care in countries for mental, neurological and substance use disorders. In the WHO Mental Health Action Plan 2013-2020, WHO Member States have committed themselves to working towards the global target of reducing the suicide rate in countries by 10 per cent by 2020.

In addition, the suicide mortality rate is an indicator of target 3.4 of the Sustainable Development Goals: by 2030, to reduce by one-third premature mortality from non-communicable diseases through prevention and treatment, and promote mental health and well being.

Ogbolu, said suicide prevention is an integral part of the first Mental Health Action Plan (MHAP) of the WHO adopted by the 66th World Health Assembly which also fits into the objective of the National Health Policy of Nigeria to reduce the burden of mental illness and promote the maintenance of sound mental health of Nigerians in general.

He said SURPIN is an initiative of the LUTH established for the purpose of suicide prevention through research, crisis intervention, health education, early treatment of depression, and drug abuse.

Ogbolu noted that the initiative is positioned to reduce the risk of suicide arising from mental health and chronic general medical conditions, through ingenious community-based approaches, cost effective crisis intervention, improved suicide record keeping, and high quality suicide-related research and education in Nigeria.

"We are positioned to be the reputable, reference centre body coordinating and maintaining global best practice in suicide research and prevention activities in Nigeria, ultimately to reduce the rate of suicide," he added.

The coordinator said Nigeria is expected to heed the call of the WHO to join hands in reducing the world suicide rate by ten percent by 2020. "In this collaborative effort, Nigeria requires functional suicide research strategies. There is a glaring lack of up to date records on suicide, yet available data so far shows that suicide is not alien to Nigeria."

The psychiatrist said that relying on statistics from WHO Global Health Observatory Data, suicide in Nigeria is at an estimated rate of 9.8 per 100,000 higher than regional average stressing that action is needed especially considering that the rate is an underestimation as many cases go unreported and undocumented.

Ogbolu continued: "The fact we have others, who might talk about suicide prevention, we talk about research and prevention and the reason why research is important is you cannot talk about solving your problem if you do not know the extent of your problem. Otherwise what you just do is to adopt somebody's approach to prevention and start to use it and it may not be ideal for you."

According to the expert, "from research, we found out that we cannot do suicide prevention without engaging religious leaders. This is because we looked at the dynamics of parts to care. When Nigerians are ill, how do they go before they get to the hospital? They go through their spiritual leaders or herbalist. So, this is the importance of research. You just do not dive into something. You have to find out what evidence supports that. So that is what made us unique."

He added: "Again because we are operating from a point of view of a federal institution. We have the goodwill of other federal institutions. What we have done, if you call our hotline, for instance, from Kano, we have a psychiatrist in Kano because we cannot treat you from here (Lagos). We now link you up. We have other mental professionals who are partnering with us all across the country."

The consultant said SURPIN is the only structured suicide prevention. It is structured such that we have zonal people to contact. You can be anywhere and we link you up with the nearest available mental health expert. We are a research and prevention initiative. The research component is important for national coverage.

Ogbolu added that the initiative is facing challenges of funding, stating that much work is needed to be done to decriminalise suicide in the criminal code of the country and address the stigma associated with mental health conditions which may put people at risk.

Similarly, a consultant psychiatrist, University College Hospital (UCH), Ibadan, Prof. Oye Gureje, stressed that eliminating mental health stigma will encourage affected persons to seek treatment and boost the quality of life.

Gureje added the challenge with depression is that people who are affected are not aware of their conditions, let alone getting treatment.

"It is also unfortunate that most symptoms will present themselves like malaria and before one will understand exactly what is happening, depression would have eaten deep. Symptoms of mental health include irritable mood, low concentration, low self-esteem, guilt, among others," he added.

Also, a consultant child and adolescent psychiatrist, UCH, Ibadan, Prof. Olayinka Omigbodun, said there is a universal intervention in preventing depression and suicide in children and adolescent to promote mental health and wellbeing and child adolescent mental health.

She called for the review of mental health laws to provide proper care for affected persons in Nigeria. "We cannot talk about the proper treatment of mental health issues if we do not have a law to back it up and we also need to understand that mental health issues affect everyone."

The psychiatrist added that the burden of depression on adolescents affect their interpersonal relationships and could be linked to other problems including smoking, drug abuse, academic failure, physically inactive and secondary behavioral problems like truancy and stealing.

To tackle the menace, Eghagha said they started a discussion group, worked with a lot of professionals, counselors, psychiatrists, psychologists, nurses, and enthusiasts, people who are also concerned in the area of suicide prevention.

Eghagha said at MASHI, they report suicide cases; we take calls from persons who are depressed, use the telephone to counsel people and when the need arises for a referral they refer them to hospitals and the individual talks to a psychiatrist.

He continued: "One of the things to do is to create awareness among young people. We have started a series of lectures among young people in secondary schools. We take a professional who talks to them about suicide. We need to inform and educate people about suicide; we need to counsel and clear minds of people against the stigmatisation that comes with seeking help.

"We need to do a documentary, in English and translate it to different languages and our partners across the country will play this in radio stations in the languages educating people. We also try to do talks, visiting the churches, mosque, and school anywhere there is assembly we talk to them and educate them about mental health."

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